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Columbia  ^Hnibcrsift^ 
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College  of  ^fjpgictans;  anb  ^urseonsf 


Reference  Hibrarp 


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THE  DISEASES 

OF  INFANTS  AND 

CHILDREN 


By 

J.  P.  CROZER  GRIFFITH,  M.D.,  Ph.D. 

Professor  of  Pediatrics  in  the  University  of  Pennsylvania,  Philadelphia; 
Physician  to  the  Children's  Hospital  of  Philadelphia,  and  to  the 
Children's  Medical  Ward  of  the  University  Hospital;  Con- 
sulting Physician  to  St.  Christopher's  Hospital  for 
Children,  Philadelphia;  Corresponding  Mem- 
ber of  the  Societe  de  Pediatric  de  Paris 


WITH  436  ILLUSTRATIONS 
INCLUDING  20  PLATES  IN  COLORS 


VOLUME  I 


Fin  LA  DELPHI  A  AND  LONDON 


W.  B.  SAUNDERS  COMPANY 

1919 


Copyright,  1919,  By  W.  B.  Saunders  Company 


IT  iX    ^1 


V    ■    \ 


PRINTED    IN    AMERICA 


Dedicated  to  the  Memory  of 

JAMES  TYSON,  M.D.,  LL.D. 

Physician,  Clinician,  Gentleman. 

My  One-time  Teacher  and 

Always  My  Trusted  Adviser  and  Friend 


PREFACE 


It  has  been  the  effort  of  the  author  in  the  following  pages  to  present  a 
review  of  the  subject  of  medical  pediatrics,  as  complete  as  seemed  desira- 
ble without  attempting  to  make  it  encj^clopedic.  Inclusion  is  made  of 
such  subjects  in  surgery  and  the  special  branches  with  the  recognition 
of  which  physicians  treating  the  diseases  of  children  should  be  more  or 
less  familiar.  While  endeavoring  to  embody  the  results  of  his  own 
experience  through  many  years  of  contact  with  disease  in  children, 
he  has  also  made  free  use  of  the  numerous  excellent  text-books  on  the 
subject,  including  the  valuable  contributions  by  American  authors, 
and  of  home  and  foreign  pediatric  journal-literature.  To  all  these 
authors  he  would  here  acknowledge  his  indebtedness. 

In  the  course  of  his  own  reading  he  has  found  quotations  from 
medical  authorities  of  much  impaired  service  unless  accompanied  by 
reference  to  the  places  of  publication,  thus  rendering  possible  the  con- 
sulting of  the  originals.  With  the  feeling  that  others  may  share  this 
sentiment,  he  has  in  footnote  form  given  the  references  to  literature 
whenever  such  quotations  are  used,  believing  that  in  this  way  the  value  of 
the  book  to  many  readers  would  be  increased,  while  the  footnote  method 
interferes  in  no  way  with  its  usefulness  to  those  others  who  are  not 
interested  in  this  line  of  research. 

Temperature-charts  and  photographic  and  other  illustrations  have 
been  reproduced  freely,  generally  accompanied  by  brief  synopses  of  the 
histories  of  the  cases,  without  which  their  value  would  be  much  lessened. 
These  are  original  or  unpublished  except  in  the  instances  where  none 
such  were  obtainable,  or  where  superior  ones  were  found  in  the  publica- 
tions of  other  writers.  Acknowledgment  has  naturally  been  made  in 
every  case. 

Throughout  the  text-book  the  metric  and  the  English  systems  of 
measurements  have  been  used  together,  putting  in  parentheses  in  the 
terms  of  one  the  equivalents  in  the  other.  The  statistics  quoted  from 
any  author  have  been  given  in  the  system  employed  by  him,  and  the 
corresponcUng  figures  in  the  other  then  placed  in  parentheses.  The 
equivalent  values  are  largely  those  found  in  the  tables  of  the  United 
States  Pharmacopoeia.  Ounces  are  respectively  avoirdupois  or  liquid 
measure,  except  in  designating  the  doses  of  solid  medicaments,  when 
Troy  ounces  are  used.  Fractional  amounts  in  grains,  drams,  cubic 
millimeters,  cubic  centimeters,  and  grams  are  omitted  unless  the  quan- 


8  *  PREFACE 

titles  are  small.  Grams  are  assumed  to  be  the  equivalent  of  cubic 
centimeters,  ignoring  the  specific  gravity  of  many  liquids,  where  the 
figures  as  given  would  not  be  absolutely  correct.  In  the  parentheses' 
the  abbreviations  designating  grams  and  cubic  centimeters  are  omitted, 
the  sense  of  the  text  making  them  unnecessary.  An  exception  to  the 
employment  of  both  systems  of  measurement  will  be  found  in  discussing 
the  preparation  of  food  in  the  artificial  feeding  of  infants.  Here  only 
English  measures  are  given,  since  the  preparation  must  be  made  in 
conjunction  with  the  graduated  nursing-bottles  and  the  liquid  measures 
in  common  household  use. 

Numerous  cross-references  will  be  found  throughout  the  work, 
thus  calling  attention  to  discussions  of  the  subjects  on  other  pages,  which 
would  otherwise  be  overlooked  unless  the  index  were  consulted. 
Although  every  effort  has  been  made  to  avoid  inaccuracy  of  statements, 
and  particularly  of  references,  the  author  must  expect  to  share  the 
experience  of  others,  that  these  will  creep  in  to  some  extent. 

The  author  has  waived  his  own  preferences  in  the  matter,  yielding 
to  the  desire  of  the  publishers  for  uniformity  in  the  system  of  spelling 
and  of  punctuation  adopted  throughout  the  numerous  works  upon 
medical  subjects  pubhshed  by  them. 

1810  Spruce  Street, 

Philadelphia,  Pa., 

September,  1919. 


CONTENTS 

DIVISION  I 
GENERAL  SUBJECTS 

CHAPTER  I 

Page 

Anatomy  and  Physiology  of  Early  Life 17 

Divisions  of  Life,  17 — The  New-bom,  19 — Development,  20— Weight,  20 
— ^Length,  27 — Head,  Trunk  and  Extremities,  31 — General  Surface,  32 — 
Head,  32 — Spine,  35 — Thorax,  35 — Abdomen  and  Pelvis,  37 — Limbs,  37 — 
Mouth  and  Teeth,  37 — Salivarj^  Glands,  40 — Esophagus,  40 — Stomach,  40 — 
Liver,  41 — Pancreas,  42 — Intestine,  42 — Digestion,  43 — Bacteria  of  Alimen- 
tary Tract,  45 — Gases,  46 — Feces,  46 — Absorption  and  Metabolism,  48— 
Gaseous  Metabolism,  52 — Organs  of  Respiration,  53 — Respiration,  54 — 
Heart,  54 — Blood-vessels,  55— Pulse,  56 — Blood-pressure,  58 — Blood,  58 — 
Genito-urinary  Organs,  59 — Urine,  60 — Thymus  Gland,  62 — Suprarenal 
Bodies,  63— Spleen,  63— Thyroid  Gland,  63— Temperature,  63— Brain,  64— 
Spinal  Cord,  64 — Development  of  Muscular  and  Nervous  Systems,  64 — 
Development  of  Special  Senses  and  of  Speech,  65. 

CHAPTER  II 

Hygiene 68 

Prenatal,  68 — First  Care  of  New-born,  68 — Bathing,  69 — Local  Toilets, 
70 — Clothing,  71 — Sleep,  74 — Exercise,  Amusements  and  School,  76 — 
Nursery,  78 — Nursing  and  Nurses,  80. 

CHAPTER  III 

Breast-feeding 82 

Ability  to  Nurse,  82 — Hygiene  of  Mother,  84 — Rules  for  Nursing,  84 — 
Causes  Interfering  with  Nursing,  86 — Signs  of  Unsatisfactory  Breast-feeding, 
87— Mixed  Feeding,  88— Weaning,  89— Wet-nursing,  90— Selection  of  ^^'ot 
Nurse,  91 — Ihunan  Milk,  92 — Quantity,  92 — Colostrum,  93 — Composition 
of  Milk,  94 — Caloric  Value,  99 — Action  of  Different  Elements,  99 — Bacteria. 
100 — Characteristics  and  Effects  of  Poor  Milk,  100 — Examination  of  Breast- 
milk,  101 — Conditions  Altering  the  Secretion  of  Milk,  103 — Modification  of 
Breast-milk,  106. 

CHAPTER  IV 

Artificial  Feeding  in  the  First  Year 108 

Mammalian  Milks,  108— Characteristics  of  Cow's  Milk,  109— Effect  of 
Heat,  109 — Effect  of  Freezing,  110 — Caloric  Value,  110 — Examination  of 
Cow's  Milk,  110 — Composition,  111 — Bacteria,  113 — Pus,  114 — Cream  and 
Top-milk,   115 — Bottom-milk  and  Skimmed   Milk,   117 — Requirements  in 

9 


10  CONTENTS 

Page 
Good  Milk,  117— Dairy  Methods,  118— Certified  Milk,  llS— General  Prin- 
ciples of  Substitute  Feeding,  119 — Modification  of  Milk,  119 — Percentage 
Feeding,  120— Caloric  Feeding,  121— Details  for  Milk-modification,  123— 
Action  of  the  Different  Milk-elements,  127 — Selection  of  Percentages,  132 — 
Quantity  and  Frequency  of  Feeding,  133 — Laboratory  Modification,  134 — 
Home  Modification,  134 — Calculation  of  Milk-formulaj,  137 — Card  for 
Ready  Calculation,  142 — To  Ascertain  Strength  of  Milk-elements  of  Mix- 
ture, 143— Whey-Foods,  145— Peptonized  Milk,  146— Buttermilk,  147— 
Casein- Milk,  148. 

CHAPTER  V 

Foods  Other  Than  Milk 150 

Protein-Foods,  150 — Amylaceous  Foods,  152 — Weight  of  Carbohydrate 
Foods,  152 — Strength  of  Gruels,  153 — Dextronized  Starch.  155. 

CHAPTER  VI 

Special  Named  Mixtures  and  Proprietary  Foods 158 

.  Special  Mixtures,  158 — -Proprietary  Foods,  160. 

CHAPTER  VII 

Diet  After  the  First  Year 169  , 

Diet  from  12  to  18  Months,  169— Diet  from  18  to  24  Months,  170— Diet  \ 

from  2  to  3  Years,  171 — Diet  from  3  to  6  Years,  172 — Amount  of  Food-ele-  ! 

ments   and  Calories  Required  after  the  1st  Year,   173 — Percentage  Com-  ] 

position  and  Caloric  Value  of  Various  Foods,  174.  i 

I 

CHAPTER  VIII  ] 

Diet  in  Illness 178  ; 

CHAPTER  IX 

Characteristics  of  Disease  in  Infancy  and  Childhood 182 

Etiology,  182 — History-taking,  183 — Methods  of  Examination,  185 — In-  i 

spection,   186 — Palpation,   188 — Percussion,  J.89 — Auscultation,  190 — Tem- 
perature-taking, 191 — Examination  of  Urine,  192 — Blood  and  Blood-pres- 
sure, 192 — Exploratory  Puncture,  192 — Radioscopy,  193 — Electric  Examina-  i 
tion,  193— Reflexes,  193.                                                                                                               j 

CHAPTER  X  ; 

Symptomatology  and  Diagnosis 194  I 

Position  and  Movements,  194 — Surface  of  Body,  195 — Face  and  Expres- 
sion, 196— Head  and  Neck,  197— Mouth  and  Throat,  198— Thorax,  198—  .■ 
Abdomen,  200 — Method  of  Sucking  and  Swallowing,  200— Respiration,  200  { 
—Pulse,  201— Temperature,  202— Cry,  202— Cough,  203— Pain,  204—  ] 
Breath,  204— Vomiting,  205— Stools,  205— Urine,  206— Blood,  207— Serous  .  i 
Fluids,  207 — Mental  and  Nervous  Symptoms,  207. 

CHAPTER  XI  1 

I 

Morbidity  and  Mortality 209 

Tendency  to  Disease  in  Infancy  and  Childhood,  209 — Fetal  Mortalit}-, 
210 — Still  and  Premature  Births,  210— Mortality  in  Infancy  and  Childhood, 
211 — Diminution  in  Death-rate,  214— Causes  of  Death,  214 — Sudden  Death, 
216. 


CONTENTS  11 

Page 

CHAPTER  XII 

Therapeutics  of  Early  Life 219 

Adyninistration  of  Medicines  by  the  Mouth,  220 — Method  of  Administra- 
tion, 220— Dosage,  222— Effect  of  and  Susceptibility  to  Certain  Drugs,  223 
— Drugs  Grouped  According  to  Action,  228 — Table  of  Dosage  at  1  Year  of 
Age,  229 — Treatment  Other  Than  with  Drugs  by  the  Mouth,  231 — Hypodermic 
Medication,  231 — Hypodermoclysis,  231 — Intraperitoneal  Injections,  232 — 
Suppositories  and  Enemata,  233 — Irrigation  of  the  Colon,  233 — Enteroclj'sis, 
235 — Inhalations,  235 — Inunctions,  237 — Applications  to  Nose  and  Throat, 
237— Counterirritation,  238— Hydrotherapy,  239— Dry  Cold,  244— Dry 
Heat,  245 — Blood-letting,  245 — Vaccine-  and  Serum-  Therapy,  245 — Intra- 
venous Injection,  245 — Transfusion  of  Blood,  246 — ^Lavage,  246 — Gavage, 
247 — Nasal  feeding,  248 — Anesthetics,  248 — Psychotherapy,  248 — ]\Iechano- 
therapy,  249 — Radiotherapy,  250 — Climatotherapy,  250. 

DIVISION  II 
DISEASES 

SECTION  I 

DISEASES  OF  THE  NEW-BORN 

CHAPTER  I 

Page 

Prematurity 252 

Characteristics  at  Different  Periods,  252 — Viability,  254 — Treatment  255. 

CHAPTER  II 
Sepsis 258 

CHAPTER  III 
Acute  Fatty  Degeneration 260 

CHAPTER  IV 
Infectious  Hemoglobinemia 262 

CHAPTER  V 

Hemorrhage 263 

Hemorrhagic  Disease  of  the  New-l>orn,  264 — Melcna,  266 — Ceplial- 
hematoma,  269 — Hematoma  of  the  Sternocleidomastoid,  272. 

CHAPTER  VI 

Icterus  

Congenital  Obliteration  of  the  Bile-ducts,  273 — Icterus  Neonatorum,  274. 


•;»7> 


CHAPTER  VII 

Asphyxia .   276 

Intrauterine  Origin,  277 — Extrauterine  Origin,  278. 


12  CONTENTS 

CHAPTER  VIII 

Pulmonary  Atelectasis 284 

CHAPTER  IX 
Congenital  Asthenia 286 

CHAPTER  X 

Diseases  op  the  Umbilicus 286 

Delayed  Healing,  286— Fungus,  287— Omphalitis,  288— Gangrene,  289— 
Arteritis  and  Phlebitis,  290 — Omphalorrhagia,  292 — Protruding  Meckel's 
Diverticulum.  295. 

CHAPTER  XI 
Mastitis 295 

CHAPTER  XII 
Ophthalmia  Neonatorum 296 

CHAPTER  XIII 

Sclerema  and  Edema 299 

Sclerema,  299— Edema,  301. 

CHAPTER  XIV 
Transitory  Fever : 302 

SECTION  II 

INFECTIOUS  DISEASES 

CHAPTER  I 

Page 

General 305 

Definition,  305 — Method  of  Dissemination,  306 — Hj'giene  and  Prophy- 
laxis, 306. 

CHAPTER  II 
Scarlatina 309 

CHAPTER  III 
Measles 336 

CHAPTER  IV 
Rubella 356 

CHAPTER  V 

Fourth  Disease  and  Erythema  Infectiosum 363 

CHAPTER  VI 

Variola 365 

CHAPTER  VII 

Vaccination 376 


CONTENTS  13 

Page 

CHAPTER  VIII 
Varicella 383 

CHAPTER  IX 

Typhoid  and  Paratyphoid  Fevers 390 

Typhoid,  390— Paratyphoid,  415. 

CHAPTER  X 

Cerebrospinal  Fever 415 

CHAPTER  XI 
Erysipelas 436 

CHAPTER  XII 
Diphtheria 443 

CHAPTER  XIII 
Grippe 472 

CHAPTER  XIV 

Pertussis 482 

CHAPTER  XV 

MtJMPS 494 

CHAPTER  XVI 
Malaria 502 

CHAPTER  XVII 

Tetanus 513 

CHAPTER  XVII 
Poliomyelitis 517 

CHAPTER  XIX 

Tuberculosis 538 

CHAPTER  XX 

Syphilis 562 

SECTION  III 
GENERAL  AND  NUTRITIONAL  DISEASES 

CHAPTER  I 

Page 

Rachitis 583 

CHAPTER  II 
Scorbutus 602 


14  CONTENTS 

Page 
CHAPTER  III 

Infantile  Atrophy 610 

CHAPTER  IV 
Malnutrition 615 

CHAPTER  V 
Rheumatism 620 

CHAPTER  VI 

The  Diatheses 630 

Exudative  Diathesis,  630 — ^Lymphatic  Diathesis,  632. 

CHAPTER  VII 
Acidosis 635 

CHAPTER  VIII 
Di.VBETEs  Mellittjs 637 

CHAPTER  IX 
Diabetes  Insipipus 641 

CHAPTER  X 
Pellagra 643 


SECTION  IV 

DISEASES  OF  THE  DIGESTIVE  SYSTEM 

CHAPTER  I 

Page 

Diseases  of  the  Mouth,  Lips,  Jaws,  Tongue  and  Salivary  Glands 648 

Hare-lip,  648 — Perleche,  649 — Anomalies  of  Dentition,  650 — Difficult 
Dentition,  651 — Alveolar  Abscess,  651 — Dental  Caries,  652 — Catarrhal  Sto- 
matitis, 652 — Aphthous  Stomatitis,  653 — Thrush,  655 — Ulcerative  Stomati- 
tis, 657 — Gangrenous  Stomatitis,  659 — Simple  Ulceration  of  the  Mouth, 
663 — Secondary  Stomatitis,  663 — Bednar's  Aphthie,  664 — Disorders  of  the 
Tongue,  664 — Disorders  of  the  Salivary  Glands,  668. 

CHAPTER  II 

Diseases  op  the  Pharynx  and  Palate 670 

Malformations  of  the  Pharynx  and  Palate,  670 — Acute  Catarrhal  Pharyn- 
gitis, 671 — Chronic  Pharyngitis,  673 — Diseases  of  the  Uvula,  673 — Pseudo- 
membranous Pharyngitis,  674 — Retropharyngeal  Abscess,  676. 

CHAPTER  III 

Diseases  of  the  Tonsillar  Tissue 679 

Tumors  of  the  Tonsil,  679 — ^Lacunar  Tonsillitis,  679 — Ulcero-membranous 
Tonsillitis,  682 — Parenchymatous  Tonsillitis,  683 — Hypertrophy  of  the 
Faucial  Tonsils,  684 — Adenoid  Growths,  686. 


CONTENTS  15 

Page 

CHAPTER  IV 

Diseases  of  the  Esophagus 691 

Malformations,  691 — Spasm,  692 — Esophagitis,  693 — Foreign  Bodies, 
695 — Retro-esophageal  Abscess,  695. 

CHAPTER  V 

Diseases  of  the  Stomach  and  Intestines 696 

Finkelstein's  Classification  of  Digestive  Diseases,  697 — Vomiting,  700 — 
Recurrent  Vomiting,  701 — Gastralgia,  704 — Anorexia,  705 — Stenosis  of  the 
Pylorus,  707 — Cardiospasm,  714 — Dilatation  of  the  Stomach,  714 — Gastric 
Hemorrhage,  716 — Gastric  Ulcer,  716 — Rumination,  717 — ^Foreign  Bodies 
in  the  Stomach,  717 — Malformations  and  Tumors  of  the  Stomach,  718— 
Acute  Gastric  Indigestion,  719 — Acute  Gastritis,  721 — Chronic  Gastritis, 
723. 

CHAPTER  VI 

Diseases  of  the  Stomach  and  Intestines  {Continued) 728 

Tympanites,  728 — Intestinal  Colic,  728 — The  Feces  in  Digestive  Dis- 
eases, 731 — Diarrhea,  733 — Acute  Intestinal  Indigestion,  736 — Acute  Gas- 
tro-enteric  Infection,  738 — Acute  Ileocolitis,  747 — Chronic  Ileocolitis,  755 — 
Constipation,  757 — Chronic  Intestinal  Indigestion,  763 — Dilatation  of  the 
Colon,  777 — Intestinal  Obstruction,  781 — Intussusception,  784 — Hernia, 
790 — Intestinal  Ulceration,  796 — Intestinal  Hemorrhage,  799 — Appendi- 
citis, 800 — Diseases  of  Meckel's  Diverticulum,  809. 

CHAPTER  VII 

Diseases  of  the  Intestine  (Continued);  Diseases  of  the  Rectum 811 

Prolapse  of  the  Rectum,  811 — Proctitis,  813 — Fissure  of  the  Anus,  814 
— Fistula  and  Abscess,  815 — Incontinence  of  Feces,  815 — Hemorrhoids, 
816 — Pruritus,  816 — Foreign  Bodies  in  the  Intestine,  817 — Morbid  Growths 
of  the  Intestine,  818. 

CHAPTER  VIII 

Intestinal  Parasites 818 

Ascaris,  819 — Oxyuris,  820 — Taenia,  823 — Uncinaria,  82S — Other  Intes- 
tinal Parasites,  831. 

CHAPTER  IX 

Diseases  of  the  Liver,  Gall-bladder  and  Pancreas 832 

Functional  Disturbance  of  the  Liver,  832 — Congestion  of  tlic  Liver,  832 — 
Icterus,  833 — Acute  Yellow  Atrophy,  837 — Enlargement  of  the  Liver,  838 
—Cirrhosis,  838— Fatty  Liver,  841— Amyloid  Liver,  841— Abscess,  842— 
Morbid  Growths  of  the  Liver,  842 — Echinococcus,  843 — Diseases  of  the  Gall- 
bladder, 843 — Diseases  of  the  Pancreas,  844. 

CHAPTER  X 

Diseases  of  the  Peritoneum 845 

Acute  Peritonitis,  845 — Sub-phrenic  Abscess,  851 — Non-tuberculous 
Chronic  Peritonitis,  851 — Tuberculous  Peritonitis,  852 — Tumors,  S59 — 
Ascites,  859. 

Index 861 


THE  DISEASES  OF  CHILDREN 

DIVISION  I 


GENERAL  SUBJECTS 


CHAPTER  I 

ANATOMY  AND  PHYSIOLOGY 
THE  DIVISIONS  OF  LIFE 

For  the  purpose  of  study  human  Ufa  is  usually  sub-divided  into  sev- 
eral stages.  These  are,  of  course,  somewhat  arbitrary  divisions,  and  vary 
considerably  with  different  writers.  As  convenient  an  arrangement  as 
any  is  that  which  separates  life  into  Intra-uterine,  or  fetal  life;  Infancy, 
including  the  New-Born  as  a  sub-division;  Childhood,  early  and  later; 
Youth  or  adolescence,  with  Puberty  as  the  initial  period  of  this  stage; 
Adult  life,  and  its  sub-division.  Old  Age. 

Intra=uterine  Life. — Although  apparently  closely  resembling  a  new- 
born child,  the  fetus  is  in  reality  so  different  that  it  is  not  capable  of  in- 
dependent existence.  Many  of  its  organs,  though  perfect,  are  not  yet 
active.  Circulation  is  not  in  the  complete  state  which  it  will  later  assume. 
Respiration  and  digestion  are  entirely  in  abeyance,  nutriment  and  oxygen 
being  obtained  through  the  maternal  blood. 

Being  so  closely  dependent  upon  the  mother  for  its  life,  it  follows  that 
the  condition  of  her  health  and  her  methods  of  living  cannot  fail  to  exert 
a  great  influence  upon  the  health  of  the  fetus,  and,  indeed,  upon  tlie  whole 
later  existence  of  the  child. 

The  fetus  may  also  directly  inherit  a  feeble  constitution  from  a  deli- 
cate father  or  mother,  irrespective  of  the  production  of  debility  by  the 
preventable  causes  mentioned.  Actual  disease  may  occasionally  be 
transmitted  from  motlier  to  fetus.  This  is  true  of  many  of  the  infectious 
disorders,  such  as  measles,  whooping  cough,  typhoid  fever,  malaria, 
syphilis,  tuberculosis  and  the  like.  The  tendency  to  rheumatism  or  to 
gout  is  directly  transmitted,  as  are  certain  nervous  disorders,  although 
the  latter  are  oftener  the  result  of  other  nervous  conditions  in  the  parents, 
or  of  imperfect  hygiene  of  the  nervous  system  of  the  mother  while 
pregnant. 

There  are,  besides,  a  variety  of  accidents  which  may  happen  to  the 
fetus  in  utero,  such  as  fractures,  dislocations,  amputations  and  the  like. 
Various  diseases  may  occur,  or  anomalies  of  development  arise,  producing 
monsters  or  lesser  degrees  of  malformations,  the  reason  for  the  occur- 
rence of  which  is  httle  understood  so  far  as  any  preventive  measures  are 
concerned.  Other  characteristics  and  disorders  of  this  period  are  fully 
2  17 


18  THE  DISEASES  OF  CHILDREN 

treated  of  in  works  upon  obstetrics  and  diseases  of  the  embryo  and  fetus. 
The  condition  of  development  seen  in  infants  the  subject  of  premature 
birth  will  be  considered  when  discussing  that  topic  (p.  252). 

The  New  Born. — The  first  period  of  infancy  is  that  in  which  the  child 
is  designated  as  New  Born.  This  term  is  applied  not  only  to  the  time 
immediately  after  birth,  but  to  a  slightly  longer  period,  regarding  the 
exact  duration  of  which  there  is  some  variance  of  opinion.  Bouchut^ 
and  Rilliet  and  Barthez,^  for  instance,  limited  it  to  the  first  few  days  of 
Ufe;  while  Henoch^  extends  it  to  the  age  of  4  to  6  weeks,  and  Parrot  to 
3  months.'*  It  seems  best  to  apply  the  title  to  the  first  2  or,  at  longest, 
3  weeks,  since  in  this  period  no  very  distinct  alterations  show  themselves 
during  the  process  of  development.  The  change  from  intra-uterine  to 
extra-uterine  life  is  so  great  that  the  new  born  are  very  subject  to  dis- 
turbances of  health,  especially  to  those  accidents  and  disorders  caused 
by  birth  or  developing  shortly  after  it.  There  are  also  a  number  of 
pathological  conditions  seen  at  birth  which  developed  during  fetal  life 
(p.  251). 

Infancy.^ — This  taken  as  a  whole  is  a  division  of  life  to  which  various 
arbitrary  and  rather  confusing  limitations  have  been  set.  A  classification 
common  especially  among  French  and  German  writers  makes  infancy 
(premiere  enfance;  Saughngsalter)  close  with  the  age  of  7  or  8  months, 
the  beginning  of  dentition,  or  with  the  age  of  1  year.  Childhood  (seconde 
enfance;  Kindersalter)  now  begins — the  first  portion  of  it  up  to  the  age 
of  about  36  months  being  called  the  period  of  the  first  dentition — and 
terminates  with  the  age  of  6  years.  Youth  (Knabensalter)  then  com- 
mences with  6  years,  and  forms  the  period  of  the  second  dentition,  lasting 
until  puberty.  Popularly,  however,  in  English-speaking  countries  in- 
fancy is  generally  considered  as  lasting  until  the  age  of  2  years  and  this 
seems  the  most  convenient  and  best  definition,  since  during  this  period 
the  important  epoch  of  the  first  dentition  is  nearly  closed,  and  features 
are  exhibited  especially  in  the  earlier  part  of  it  which  differ  in  many 
respects  from  those  seen  in  the  later  years  of  child-life.  Children  in  the 
first  year  may  be  called  nurslings. 

Development,  both  of  the  body  and  of  the  mind,  during  infancy  is 
very  rapid,  except  that  for  the  first  few  months  there  is  little  discoverable 
gain  in  intellectual  power.  Infants,  especially  those  of  an  early  age,  are 
extremely  susceptible  to  external  depressing  influences,  such  as  cold  and 
fatigue,  and  often  easily  affected  by  drugs,  and  rapidly  exhausted  by 
disease.  On  the  other  hand,  they  exhibit  remarkable  recuperative  power 
when  recovery  begins. 

Childhood. — According  to  the  classification  adopted  here  the  term 
childhood  is  best  used  to  cover  the  period  from  the  close  of  infancy  to 
the  development  of  puberty.  It  may  conveniently  be  divided  into  Early 
Childhood  from  the  age  of  2  to  that  of  6  years,  the  latter  marking  the  be- 
ginning of  the  second  dentition,  and  Later  Childhood  (Knabensalter)  from 
the  age  of  6  years  to  puberty. 

During  childhood  growth  continues  with  a  rapidity  which,  though 
great,  is  less  than  in  infanc3^  The  mental  and  physical  differences  be- 
tween the  sexes  become  constantly  more  apparent.  The  nervous  system 
is  still  much  in  evidence  although  to  a  less  extent  than  in  infancy.     The 

1  Maladies  des  nouvcau-ncs,  1885,  1. 

2  Sanne,  Maladies  des  enfants,  1884,  I,  5. 

3  Vorlesungen  iiber  Kinderkrankheiten,  1895,  21. 
*  Clinique  des  nouveau-nes,  1877,  4. 


THE  NEW  BORN 


19 


incidence  of  diseases  at  different  periods  of  infancy  and  childhood  will 
be  discussed  later  (p.  209). 

Youth. — According  to  the  generally  accepted  definition  the  term 
Youth  or  Adolescence  is  applied  to  the  period  beginning  with  puberty 
and  terminating  with  the  commencement  of  adult  life;  i.e.,  21  to  25  j^ears. 
The  exact  time  for  the  development  of  puberty  varies  not  only  with 
individuals  but  with  race  and  climate.  In  general  for  temperate  climates 
it  may  be  placed  at  from  14  to  16  years  for  bo3^s  and  from  12  to  15  years 
for  girls.  Common  law  places  it  at  14  years  for  males  and  12  years  for 
females.  With  the  occurrence  of 
puberty  the  sexual  functions  are  es- 
tabhshed  in  both  sexes,  the  genital 
organs  increase  in  size,  and  the  growth 
of  hair  begins  upon  the  pubis  and 
later  in  the  axillae.  In  the  female  the 
breasts  enlarge  and  become  rounded 
by  a  deposit  of  fat.  In  the  male  the 
voice  changes  and  hair  begins  to  grow 
upon  the  face.  The  psychic  charac- 
teristics belonging  to  each  sex  now 
become  accentuated.  The  attributes 
and  diseases  most  peculiar  to  youth 
do  not,  of  course,  come  under  special 
consideration  in  the  study  of  pediatrics. 

THE  NEW  BORN 


The  infant  at  birth  is  more  or  less 
covered  by  a  white,  waxy  substance, 
the  vernix  caseosa,  which  protected  it 
during  fetal  life.  This  is  especially 
abundant  on  the  flexor  surfaces,  the 
back  and  in  the  folds  of  the  body, 
although  some  children  have  almost 
none  of  it  upon  them.  It  is  composed 
of  the  thickened  secretions  of  the 
sebaceous  glands  and  of  scales  of  epi- 
dermis. When  it  has  been  removed 
by  washing   the   skin  is  found  to  be 

thin,  smooth,  delicate  and  of  a  deep-reddish  color.  The  lanugo  char- 
acteristic of  fetal  life  has  generally  largely  disappeared  in  fully  developed 
new-born  children.     Many  infants,  however,  still  show  a  fine  soft  down. 

The  child's  flesh  should  be  plump  and  firm  from  a  good  development 
of  subcutaneous  fat.  The  head  is  ])roportionately  very  large  and  often 
rather  thickly  covered  with  long  hair.  The  eyes  are  an  indeterminate 
blue,  and  are  usually  kept  shut  or  but  half  open.  The  face  is  expression- 
less. The  chest  is  small  and  narrow  and  the  al)domen  large  and  promi- 
nent. The  arms  are  short  and  are  held  most  of  the  time  flexed  antl 
pressed  against  the  body  in  the  position  maintained  in  the  uterus. 
The  hands  are  generally  closed,  but  will  grasp  firmly  any  object  placeil 
in  them.  TIh^  nails  are  well  developed,  and  project  beyond  the  tips  of 
the  fingers  and  toes.  The  legs  are  comparatively  small  and  short,  and 
apparently  curved  with  an  outward  bow  (Fig.  1).  They  are  nuich  of  the 
time  held  flexed  at  the  knees  and  drawn  up  to  the  abdomen  as  in  the  fetal 


Fig.  1. — Ti.KiiY  a  Fkw  Wkeks  Old, 
Showing  the  N.\tural  Curve  of  the 
Legs  with  the  Bending  in  of  the 
Soles.      (From  a  photograph.) 


20 


THE  DISEASES  OF  CHILDREN 


position.     Intellectual  activity  is  practically  absent  and  the  power  of  the 
special  senses  largely  in  abeyance. 

DEVELOPMENT 

A  more  detailed  study  is  necessary  of  the  characteristics  of  the  new- 
born child  and  of  its  development  as  growth  advances.  These  subjects 
will  be  considered  in  course. 

Increase  in  Weight.^ — -The  weight  of  the  normal  healthy  child  at 
birth  may  be  taken  as  from  7  to  ll^  lb.  (3175  to  3402).  The  children 
of  primiparse  are  slightlj"  lighter  than  those  of  multiparae,  the  difference 
averaging  about  5  oz.  (142).  Investigations  by  Dr.  J.  C.  Gittings  and 
myself  upon  226  new-born  infants  gave  an  average  initial  birth-weight 
of  3455.79  grams  (7.62  lb.).  There  is,  however,  a  great  range  in  the 
weight  of  the  new  born  even  within  physiological  limits.  This  is  shown 
by  the  variation  in  the  statistics,  as  seen  in  the  following  table: 
Table  1. — Average  Weight  at  Birth 

Kezmarsk}-^ 73  cases         Average  3330  grams  (7.34  lb.) 

Ingerslev^ 3450  cases 

Holt^ 1158  cases 

Schaffer^ 94  cases 

Camerer^ 119  cases 

Peterson^ 1675  cases 

Griffith  and  Gittings^ 226  cases 

Fuhrmann* 1000  cases 

Male  children  are  somewhat  heavier  than  female,  the  difference  being 
about  100  to  200  grams  (3.5  to  7  oz.).  In  the  observations  of  Gittings 
and  myself  HI  males  averaged  3494.06  grams  (7.70  lb.),  and  115  females 
3418.08  grams  (7.54  lb.).  Some  of  the  statistics  illustrating  the  differences 
between  the  sexes  are  seen  in  the  following  table: 

Table  2. — Birth-weight  of  Male  and  op  Female  Infants  Respectively 


Average  3334  grams  (7.35  lb.) 
Average  3330  grams  (7.34  lb.) 
Average  3151  grams  (6.95  lb.) 
Average  3433  grams  (7.57  lb.) 
Average  3527  grams  (7.78  lb.) 
Average  3456  grams  (7.62  lb.) 
Average  3337  grams  (7.36  lb.) 


Males 

Females 

Ingerslev* 

3381  grams  (7.45  lb.) 
3386  grams  (7.46  lb.) 
3200  grams  (7.05  lb.) 
3214  grams  (7.08  lb.) 
3383  grams  (7.46  11).) 
3400  grams  (7.49  1b.) 
3595  grams  (7.92  lb.) 
3494  grams  (7.70  lb.) 

3280  grams  (7.23  lb.) 

Gregory^" 

Quetelet" 

Altherri- 

3331  grams  (7.34  lb.) 
2910  grams  (6.41  lb.) 
3077  grams  (6.78  lb.) 

Kfizmdraky" 

Holt" 

Peterson'* 

3284  grams  (7.21  lb.) 
3260  grams  (7.24  lb.) 
3455  grams  (7.62  lb.) 

Griffith  and  Gittings^o 

3418  grams  (7.54  lb.) 

1  Arch.  f.  Gvnak.,  1873,  V,  547. 

2  Nord.  Med.  Ark.,  1875,  VII,  No.  7,  8. 

3  Dis.  of  Inf.  and  Childh.,  1911,  16. 

*  Arch.  f.  Gvnak.,  1896,  LIII,  616. 

*  Jahrb.  f.  Kinderheilk,  1901,  LIII,  413. 

«  Upsala  lakeref.  forhandl.,  1882,  XVIII,  15. 

'  Arch,  of  Ped.,  1907,  XXIV,  321. 

8  Med.  Khnik,  1907,  III,  510. 

^  Loc.  cit. 
'»  Arch.  f.  Gynak.,  1871,  52. 
'1  Sur  I'homme  et  le  development,  etc.,   1836,  II,  49. 

Ref.  Flei.schman,  Wiener  Klinik,  1877,  June  and  July. 
'-  Ueber  regelmassige  Wiigung  der  Xeugeborenen,  1874. 
^^  Loc.  cit. 
^*  hoc.  cit. 
^^  Loc.  cit. 
^^Loc.  cit. 


DEVELOPMENT  21 

Immediately  after  birth  the  loss  of  weight  begins  in  nearly  all  cases. 
This  depends  upon  the  excretion  of  meconium  and  urine,  the  loss  of  the 
vernix  caseosa,  the  excretions  of  the  skin  and  lungs  and  the  metabolic 
changes  progressing  in  the  tissues.  The  weight  of  meconium,  urine  and 
vernix  ranges  from  3  to  5  oz.  (85  to  142)  according  to  the  observations  of 
Townsend.^  A  review  made  by  Fleischman^  of  the  results  obtained  by 
a  number  of  observers  showed  it  to  average  222  grams  (7.83  oz.);  i.e., 
about  Ks  (6.66  per  cent.)  of  the  whole  weight  if  we  assume  this  as  3300 
grams  (7.28  lb.).  Certain  other  observations,  however,  give  a  loss 
somewhat  greater  than  this  as  physiological.  In  an  examination  of  226 
infants  made  by  Gittings  and  myself^  the  total  average  loss  equalled 
about  11  oz.  (312),  the  relative  loss  being  approximately  }y'i\  (9  per 
cent.)  of  the  initial  weight.  It  is  usually  accepted  that  the  heavier  the 
full-term  baby,  the  greater  will  be  the  absolute  loss  of  weight;  and 
it  would  appear  from  the  studies  of  Longridge*  that  the  relative  loss  is 
also  greater.  Thus  in  400  infants  examined  by  him,  the  7-lb.  children 
lost  }/^^  of  their  body-weight,  and  the  5-lb.  children  only  3'l6-  Pies'^ 
studies  did  not  confirm  this.  The  loss  of  weight  is  physiological,  and 
usually  cannot  be  entirely  prevented.  Observations  carried  out  by 
Gittings  and  myself^  on  61  infants  confirmed  the  results  of  Cramer' 
and  others,  that  by  wet-nursing  from  the  beginning  until  the  mother's 
secretion  is  established,  the  initial  loss  of  weight  could  be  reduced  very 
considerably,  yet  that  this  offered  no  great  advantage.  Keilman* 
found  that  when  artificial  feeding  was  commenced  immediately  after  birth, 
the  infants,  although  losing  somewhat  less,  regained  the  initial  weight 
more  slowly  than  did  those  who  had  been  nourished  solely  at  the  mother's 
breast. 

The  diminution  of  weight  continues  until  the  3d  or  4th  day  and 
sometimes  even  longer,  but  cannot  in  the  latter  event  be  called  physio- 
logical. The  greatest  loss  takes  place  on  the  1st  day,  from  3.5  to  4  per 
cent.,  and  the  next  upon  the  2d  day,  2  to  2.6  per  cent,  of  the  birth-weight. 
The  3d  day  shows  usually  but  little  loss  or  the  beginning  of  gain.  The 
original  weight  is  not  regained  before  the  8th  or  9th  day,  and  often  not 
until  the  14th  day.  In  a  study  upon  600  infants  by  Schulz,^  288,  or  48 
percent.,  had  regained  their  original  weight  in  10  days,  illness  of  a  number 
of  the  children  preventing  an  earlier  average  time  of  regain. 

Published  statistics  regarding  the  influence  of  sex  are  contradictory, 
some  showing  a  greater  loss  in  males,  others  in  females.  In  our  own^" 
studies  upon  105  infants,  the  average  loss  in  boys  was  somewhat  greater 
and  the  regain  of  the  initial  weight  slower  in  being  accomplished.  Town- 
send''  noticed  that  children  of  primiparse  lose  about  13^2  oz.  (42)  more 
than  those  of  multipanc. 

The  chart  which  follows'-  (Fig.  2.)  shows  the  loss  and  regain  of 

>  Boston  Med.  and  Surp;.  Journ.,  1887,  CXVI,  1.57. 

2  Wicnor  Klinik,  1877,  June-July. 

•■'  Ijoc.  cit. 

'  Brit.  .Jour.  Child.  Dis.,  1905,11,  40.5. 

^  iVIonatsschr.  f.  Ivinderh.,  Orig.,  1910,  IX,  .514. 

'  Loc.  cit. 

'  Miinch.  nied.  Woch.,  1900,  XLVII,  1.5S.5. 

s.Iahrl).  f.  Kindcrli.,  l.S9(;,  XLI.  :U2. 

»  InauK.  Dissert.  CJrcifswald,  1903.      Kef.  Arch.    f.  Ivindnli.,  l',)()l.  XXXIX.  J07. 
"  Griffith  and  Gittings,  loc.  cit.,  33(5. 
"  Loc.  cit. 
"  New  York  Med.  Journ..  1SS9,  Marcli  4. 


22 


THE  DISEASES  OF  CHILDREN 


weight  in  the  first  10  days  according  to  the  observations  of  a  number  of 
investigators. 

After  gain  in  weight  begins  increase  is  rapid.  Various  estimations 
have  been  made  of  its  rate,  some  of  the  more  important  of  which  are 
shown  in  graphic  form  in  the  illustration  (Fig.  3). 

Quetelet^  assumed  that  growth  continues  at  the  same  rate  throughout 
the  first  year;  hence  his  line  in  the  chart  is  a  straight  one.  Later  investi- 
gations show  that  the  rate  of  growth  progressively  decreases,  this  factor 
making  the  graphic  plotting  a  curved  line. 

7.  '■  sV    fO^ 


Fig.  2. — Graphic  Cukves  Showing  Gain  and  Loss  of  Weight  in  the  First  10  Days 

OF  Life. 
According  to  different  observers.     {Griffith,  New  York  Med.  Journ.,  1899,  March  4.) 

It  must  be  remembered  that  all  tables  of  weight  represent  only  the 
average  rate  of  growth.  A  considerable  variation  in  the  individual  child 
within  physiological  limits  is  possible. 

The  following  figures  give  approximate  weights  of  well-developed 
breast-fed  children  during  the  first  year  of  life.  They  follow  to  a  con- 
siderable extent  the  investigations  of  Camerer^  and  start  with  a  birth- 
weight  somewhat  higher,  viz.,  3400  grams  (7>^  lb.),  than  that  given  by 
many  investigators. 

1  Ref.  rieischmann,  loc.  cit. 

2  Jahrb.  f.  Kinderh.,  189.3,  XXXVI,  249. 


DEVELOPMENT 

Table  3. — Showing  Increase  in  Weight  During  the  First  Year 

Age  Weight 

-    .    Birth 7      lb.    8  oz.  (3402) 

1  week 7      lb.    7J^  oz.  (3388) 

2  weeks 7      lb.  lOH  oz.  (3473) 

3  weeks 8      lb.    2  oz.  (3685) 

1  month 8^4  lb.  (3969) 

2  months 10341b.  (4876) 

3  months 12341b.  (5557) 

4  months 13341b.  (6237) 

5  months 15      lb.  (6804) 

6  months 16M  lb.  (7371) 

7  months 173^  lb.  (7824) 

8  months 183^  lb.  (8278) 

9  months 18341b.  (8505) 

10  months 1934  lb.  (8958) 

11  months 20K  lb.  (9299) 

1  year 211^  lb.  (9752) 


23 


fAss!±i..    /.     S.,    i     -i     s     6.    7.     i.,    '•/  ■:     /.'.    -^  .  ,     -^-    -■;    -'      -"?   r 

YtfcAv     ^     »'    a  '  ic'  2u    2M\it  \ii  \}t.   'fie.  J^'  A»   SI   itt  -  <■».   &4!   it    7J ;  ;«.  j  i"  ,  *^  ;W   y^  jf<.   4»   <» 


/\i 


Mii.gkt       Curvts       «/ 

'  -  Htijch  »>vo.>v>i..   ,K.—  KfjLt".     li.— lionvj 
BciuJiuuo,.        Q..—    Q.iM.t'tltt'. 

Fio.  3. — Gn.vPHic  CrnvEs  Showing  the  Normal  Gain  in  Weight  During  the  1st  and 

2d  Year.s. 
Several  observers.     {Griffith,  New  York  Med.  Journ.,  1899,  March  4.) 

Analyziiis  tlicso  figures  it  will  be  noticed  that  in  the  last  3  weeks  of 
the  1st  month  and  during  the  2d  month  the  gain  in  weight  is  about  1 
oz.  (28)  a  day,  7  oz    (198)  a  week;  in  the  3d  and  4th  months  slightly 


24  THE  DISEASES  OF  CHILDREN 

over  ^-i  of  an  oz.  (21)  a  day,  b\i  oz.  (156)  a  week;  in  the  5th  and  6th 
months  %  of  an  oz.  (19)  a  day,  4%  oz.  (132)  a  week,  and  in  the  re- 
mainder of  the  1st  year  about  j-^  oz.  (14)  a  day,  3^4  oz.  (106)  a  week, 
or  1  lb.  (454)  a  month;  except  that  somewhere  about  the  9th  month 
there  is  Hable  to  be  a  temporary  diminution  in  the  rapidity  of  increase. 

The  initial  average  weight  is  doubled  at  the  age  of  5  months  and 
trebled  at  the  age  of  1  year.  Rauditz  ^  has  formulated  a  certain  law  ac- 
cording to  which  the  increase  in  weight  shall  bear  a  certain  definite 
mathematical  relation  to  the  age.  The  application  of  the  rule  is,  however, 
not  ver}^  practical. 

The  weight  of  males  during  the  1st  year  is  on  the  average  somewhat 
greater  than  that  of  females,  amounting  at  the  age  of  a  year  to  a.difference 
of  ^  up  to  even  1>:^  lb.  (227  to  567).  Children  fed  artificially  gen- 
erally gain  weight  less  rapidly  than  those  at  the  breast,  but  this  is  by  no 
means  an  invariable  rule.  This  difference  in  weight  depending  on  the 
food  may  persist  during  the  first  3  or  4  years,  but  very  often  a  healthy 
infant  artificially  fed  and  thriving  on  its  diet,  even  although  temporarily 
behind,  will  equal  the  breast-fed  child  in  weight  by  the  end  of  the  1st 
year. 

There  are  but  few  extended  observations  made  upon  the  weight  of 
children  from  the  1st  to  the  6th  year.  Those  of  Camerer^  appear  reliable. 
The  weights  obtained  by  him  are  as  follows: 

Table  4. — Increase  in  Weight  from  the  Second  to  the  Fifth  Year  of  Life 

Inclusive 

(Camerer) 

12  months 10,030  grams  (22. 11  lb.) 

13  months 10,220  grams  (22. 53  lb.) 

14  months 10,000  grams  (23.36  lb.) 

15  months 10,870  grams  (23.96  lb.)  . 

16  months 10,900  grams  (24.03  lb.) 

17  months 11,450  grams  (25.24  lb.) 

18  months 11,480  grams  (25.30  lb.) 

19  months 11,850  grams  (26. 12  lb.) 

20  months 12,050  grams  (26.56  lb.) 

21  months 11,950  grams  (26.34  lb.) 

22  months 12,200  grams  (26 .  80  lb.) 

23  months 12,480  grams  (27. 51  lb.) 

2  years 12,740  grams  (28.08  lb.) 

3  years 14,930  grams  (32.91  lb.) 

4  years 16,410  grams  (36.16  lb.) 

5  years ^_  18,710  grams  (41 .25  lb.) 

The  studies  of  Perret  and  Planchon^  give  figures  about  100  grams  (3.53 
oz.)  less  than  these.  Those  of  Freeman^  upon  278  well  cared  for  children 
in  private  practice  gave  results  decidedly  higher,  as  is  to  be  expected. 
In  general  it  may  be  assumed  that  the  average  healthy  infant  gains  in  its 
2d  year  from  5  to  6  lb.  (2268  to  2722) ;  i.e.,  Y^  lb.  (227)  a  month  or  \i  oz. 
(7)  a  day,  the  increase  in  the  1st  half  of  the  year  being  greater  than  in 
the  2d  half.  (See  chart,  p.  28.)  In  the  3d  and  4th  years  the  child 
gains  about  5  lb.  (2268)  and  in  the  5th  year  about  4  lb.  (1814).  In 
tabular  arrangement  the  figures  read  as  follows: 

1  Prag.  med.  Wochenschr.,  1892,  Nos.  7  and  8. 

2  .Jahrb.  f.  Kinderheilk.,  1901,  LIII,  418. 

3  L'Obstctrique,  1904,  IX,  193. 

<  Amer.  Jour.  Dis.  Child.,  1914,  VIII,  321. 


DEVELOPMENT  25 

Table  5. — Gain  in  Weight  from  One  to  Fhe  Years 
End  of  1st  year  weighs  21  ^.^  lb.  (  9,752) 

End  of  2d  year  weighs  27  lb.  (12,247)  Gained  53^  lb.  (2495) 
End  of  3d  vear  weighs  32  lb.  (14,515)  Gained  5  lb.  (2268) 
End  of  4th  year  weighs  37  lb.  (16,783)  Gained  5  lb.  (2268) 
End  of  5th  year  weighs  41      lb.  (18,597)      Gained  4      lb.  (1814) 

Girls  continue  to  be  from  1  to  IJ--^  lb.  (454  to  680)  lighter  than  boys  to 
the  end  of  this  period. 

The  following  table  shows  the  mean  rate  of  increase  for  the  two  sexes 
according  to  the  observations  of  Camerer:^ 

Table  6. — Gain  in  Weight  of  Boys  and  Girls  Respectively 

(Camerer) 

I     .  Boys  Girls 

1st  year !  10,310  grams  (22.73  lb.)  i         9,460  grams  (20.86  lb.) 

2d  year I  13,210  grams  (29. 12  lb.)  i       12,010  grams  (26.48  lb.) 

3d  year !  15,460  grams  (34.08  lb.)  !       13,970  grams  (.30.78  lb.) 

4th  year '  16,810  grams  (37.08  lb.)  15,720  grams  (34.66  lb.) 

5th  year 19,300  grams  (42.59  lb.)  17,540  grams  (.38.67  lb.) 

Estimating  roughly  the  combined  average  weight  of  the  sexes  we 
find  children  gaining  about  4  lb.  (1814)  in  the  6th  and  7th  years,  4)^^ 
lb.  (2041)  in  the  8th,  5  lb.  (2268)  in  the  9th,  5^  to  6  lb.  (2495  to 
2722)  in  the  10th  and  11th  years,  7  to  8  lb.  (3175  to  3629)  in  the  12th 
year,  and  then  from  9  to  10  lb.  (4082  to  4536)  a  j^ear  to  the  age  of  16 
years.  In  tabular  form  the  approximate  weight  for  the  dijfferent  years 
according  to  this  rate  of  increase  reads  as  follows : 

Table  7. — Weight  from  Six  to  Sixteen  Years 

6  years 45      lb.  (20,412) 

7  years 49      lb.  (22,226) 

8  years 53j-^  lb.  (24,267) 

9  years 58^^  lb.  (26,535) 

10  years 64  lb.  (29,030) 

11  years 70  lb.  (31,751) 

12  years 78  lb.  (35,380) 

IS* years 87  lb.  (39,463) 

14  years 96      lb.  (43,549) 

15  years 106      lb.  (48,080) 

16  years 116      lb.  (52,617) 

It  will  be  seen  that  the  child  nearly  doubles  its  weight  at  1  j-ear  by 
the  age  of  5  years,  and  trebles  it  by  10  years. 

The  difference,  however,  which  the  sexes  show  in  the  rate  of  increase 
in  weight  is  so  decided  in  later  childhood  and  in  youth,  that  a  separate 
consideration  is  necessary.  The  rate  of  growth  continues  about  the 
same  in  each  sex  until  about  the  age  of  8  or  9  years,  at  which  time  the 
increase  in  girls  is  somewhat  retarded,  and  boys  advance  decidedly 
beyond  them.  By  11  years,  however,  girls  begin  to  gain  in  weight 
rapidly,  and  by  12  years  decidedly  surpass  boys.  This  continues  until 
the  age  of  15  or  16  years  when  boys  again  take  and  maintain  the  lead. 
The  relative  weights  and  rates  of  increase  in  boys  and  girl.-^  respectively 
during  this  period,   according  to  the  statistics  of  Bowditch,-  Porter^ 

'  hoc.  oil- 

2  8th  Ann.  Rep.  Mass.  State  Board  of  Health,  1877.  275. 

3  Transac.  Acad.  Science,  St.  Louis,  VI,  No.  12,  312. 


26 


THE  DISEASES  OF  CHILDREN 


and  Peckham,^  can  be  learned  from 
of  Bowditch  are  based  upon  24,595 


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the  following  table.  The  figures 
observations  upon  public  school- 
children of  Boston;  those  of 
Porter  upon  30,817  children  of 
St.  Louis,  and  those  of  Peckham 
upon  5403  children  of  Mil- 
waukee. 

The    figures    given    in    this 
table  are  those  for  children  of 

5  years  and  over  including 
clothing.  Those  for  younger 
periods  (p.  25)  are  without 
clothing.  The  average  weight 
of  the  clothes,  as  estimated  by 
Schmidt-Monard^  is  6  per  cent, 
to  7  per  cent,  of  the  weight  of 
the  body  at  the  age  of  from  3  to 

6  years,  and  7  per  cent,  to  8  per 
cent,  from  6  to  14  years.  Ac- 
cording to  a  series  of  personal 
estimations  made  on  over  200 
children,  the  average  weight  of 
the  clothes  in  the  1st  year  is  ap- 
proximately l^i  lb.  (794) ;  from 
1  to  4  years,  2  lb.  (907);  and 
from  4  to  6  years,  2}4,  to  2}y^  lb. 
(102  to  113).  The  ratio  of  the 
weight  of  the  clothing  to  the 
gross  weight  of  the  normal  child 
dressed  is  approximately  16  per 
cent,  in  the  first  3  months,  but 
after  this  during  the  first  2  years 
approximately  8  per  cent,  to  10 
per  cent. ;  and  from  2  to  5  years 
6  per  cent.  Bowditch^  estimates 
the  weight  of  the  clothes  at  5 
years  for  boys  as  2.8  lb.  (1270); 
equalling  6.45  per  cent,  of  the 
total  gross  weight  for  boys,  and 
for  girls  as  2.84  lb.  (1288)  or  6.79 
per  cent,  of  the  total  weight  for 
that  sex;  at  8  years  4  lb.  (1814) 
or  7.23  per  cent,  for  boys  and 
3.5  lb.  (1587)  or  6.54  per  cent, 
for  girls;  at  11  years  6.7  lb. 
(3039)  or  9.88  per  cent,  for  boys, 
and  4.9  lb.  (2223)  or  6.88  per 
cent,  for  girls;  at   14  years  8.1 

1  6th    Ann.    Rep.    State   Board  of 
Health,  Wisconsin,  1881,  p.  28. 

2  Jahrb.  f.  Kinderheilk.,  1901,  LIII, 
53. 

3  Loc.  cit.,  306. 


DEVELOPMENT 


27 


lb.   (3674)   or  8.15  per  cent,  for  boys  and    7.5  lb.  (3402)  or  6.76  per 
cent,  for  girls. 

The  influence  of  any  illness  upon  the  increase  of  weight  is  very  decided, 
especially  in  infancy.  Growth  ceases,  and  weight  may  even  be  rapidly 
lost,  depending  upon  the  nature  of  the  disease.  There  appears  to  be  a 
positive  influence  of  season  upon  the  growth  of  children.  The  investiga- 
tions of  Malling-Hansen^  upon  children  of  from  9  to  17  years  showed  the 
most  rapid  increase  occurring  from  August  to  December.  Schmidt- 
Monard-  confirms  this  for  even  younger  children  from  the  age  of  23^^  years 
and  even  in  the  2d  year,  and  Bleyer^  found  it  true  even  of  the  first  year 
of  life.  Indeed  the  influence  of  the  season  may  extend  so  far  that,  as 
claimed  by  Stepanoff,^  children  of  the  school  age  who  were  born  in  summer 
are  larger  than  those  born  in  winter. 


Fig.  4. — Balance  Scales  for  Weighing  In'fants. 

The  importance  of  weighing  children  regularly  during  the  first  2  years 
of  life,  and  especially  during  the  1st  year,  cannot  be  over-estimated,  since 
cessation  of  gain  is  often  the  first  sign  of  illness,  or  of  a  lack  of  sufficient 
nourishment.  The  child  should  be  weighed  at  least  weekly,  divested  of 
clothing  or  dressed  and  the  weight  of  the  clothes  subsequently  deducted. 
Scales  should  be  used  which  indicate  ounces.  Standing  spring  scales 
with  a  scoop  or  basket  attached  are  very  convenient,  but  some  form  of 
balance  scale  is  more  accurate  (Fig.  4).  For  recording  the  results  a 
weight  chart  is  a  great  convenience.  The  illustration  (Fig.  5)  is  a  reduced 
reproduction  of  one  which  I  have  employed  for  a  number  of  years. ^ 
The  curve  already  plotted  upon  it  represents  the  normal  average  gain 
in  weight  for  a  healthy  breast-bed  infant.  To  economize  space  the  por- 
tion for  the  2d  year  is  narrowed  one-half,  which  necessarily  distorts 
the  line.  A  very  convenient  form  for  recording  dailj^  weighings  is  that 
employed  at  The  Children's  Hospital,  Philadelphia,  of  which  a  reduced 
reproduction  is  shown  (Fig.  6). 

Length. — Estimations  upon  growth  in  length  in  the  first  year  have 
not  been  nearly  so  numerous  as  those  upon  weight,  and  the  results  of 

1  Porioden  in  Gewicht,  etc.,  Copenhagen,  1886.  Ref.  Vierordt's  Daten  u.  Tabellen, 
1906,  25. 

*  Loc.  cit. 

3  Arch,  of  Pediat.,  1917,  XXXIV,  366. 

*  Thdse  dc  Lausanne.     Ref.  Monatsschr.  f.  Kindorhoilk.,  1903,  II,  242. 

^  W.  B.  Saunders  Co.     For  sale  singly  by  E.  Pcnnock,  3009  Woodhind  Ave,  Plnla. 


28 


THE  DISEASES  OF  CHILD  REX 


different  observations  show  decided  variations,  since  accurate  deter- 
mination requires  much  care.  The  average  length  at  birth  may  be 
assumed  as  49.5  to  50  cm.  (19.5  to  20  inches),  with  males  about  0.5  to 

DawcpiDkT)    P  LttOZIRCBlFFITH.M  D.. 

INFANTS  WEIGHT  CHART.      "-".i:"^;-;^;-; "- 


Months.  1            «                         1            ?            ' 
Weeks  i        1           1     i       j   r     n|    h    2.I  ii   « 

„  „i„  „  1.  „  1  „  j„  x,  „," ; 

\ 

I 

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at 

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:  .:    :^"  ^-''  :            :    ~ 

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. 

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~ 



„::::::::::::z::::::::::::: 





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--  —    ---^       -  -       '  - 





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u 

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z  ""         — 

t-.y 

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1 1 1 

— 



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' 

^ 

__ 

Weeks.  1    >     i     :     1    11    u    li   11    it    ai   21   1 

n   »  »   n  w  n   M   41  «   4>  «   M   ti 

• 

to 

H 

U 

• 

n 

N) 

B4 

W 

n'i 

»« 

00 

M 

Fig.  5. — Auxuou's  Weight  Chakt  for  the  First  2  Years  of  Life. 
Reduced  size.     (New  York  Med.  Journ.,  1899,  March  4.) 

1  cm.  (0.2  to  0.4  inch)  longer  than  females.  Gain  in  length  goes  on 
rapidly  but  with  decreasing  speed.  Thus  in  the  first  3  months,  according 
to  Camerer,^  the  gain  is  9  cm.  (3.5  inches),  in  the  next  3  months  8  cm. 

1  Jahrb.  f.  Kinderh.,  1901,  LIII,  425. 


DEVELOPMENT 


29 


(3.2  inches),  and  in  the  third  and  fourth  3-month  periods  3  to  5  cm. 
(1.2  to  2  inches),  making  a  total  gain  of  24  cm.  (9.4  inches)  for  the  year. 
These  figures  are  somewhat  in  excess  of  certain  other  statistics.     Heubner  ^ 


Infant's  Weight   Chart 

!                  Ill 

D,y ///////  /\/  ////  /\/  //  /\/\/  //////  / 

( 

r              11        1     ■  ■"       "T               ■; .__ .  ■ 

III                      1                               .__:_..                             1 

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'            II   1       1          I    1    1    1       1   1    1    M    1              1    1                                   1              1      ■ 

13    II  Ml  1  !  1  1  1  1  1  1  1  1  M  1  1  i  1  I  1  !  1  1  M  1  1  II  M  1  1  M  M  II  M  M  1  1  M  M  II  1 

1         1  1  ■         i  1  1  1  J  i      1      !           i      ;  L       J.     L  _LLLU1L_L.  _     L             L        LL  _  J 

Z    li  1  1  1  1  !  M  1  !  1  II  i  1  1  11  1  1  1  M  1  r  1  1  I  1  i  1  1  1  1  1  1  1  1  1  1  1  1  1  1  1  1  1  1  1  1  1  M  1  1 

.     1            i  1  i   1  i  '      :  ;   :  1      1         1      1   I         1      1            1            LL                                               1 

-^    1  M  M  M  M  i  h  M  '  11  1  1  i  i  !  1  M  '  1  1  1  1  1  ]  I  M  1  1  1  1  1  1  1 '1  1  1  1  1  I  II  1  1  1  1 

0  II  i  1  1  1  h  1  'i  1  i  1  I  ;  1  1  1  1  1  1  M  1  1  1  1  1  1  I  1  !  !  '  M  1  il  1  1  M  1  M  1  1  1  1  M  1  1  1 

"    :            1                    1                !                i    1            1            i       .1    1    1    M    1 

1 

i 

i 
1 

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L                          1    1            1          '       .   1                1                !    1                  '                  1 

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!            '        :                :    1                •                i 

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1    '                    '                                                                                 1 

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±                      ±  iL                                     i^                 1 

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1                         1                       ■       1       J 

Fig.  G. — Daily  Wkight  Chaut. 
To    be    used  for    daily    weighings    at  any    period  of  infancy.     As  employed   ill    the 
Children's  Hospital  and  in  the  Cliildren's  Medieal  Ward  of  the  University  Hospital. 
Philadelphia.      Rodufcd  .size. 

gives    the    following    table   for    average    figures   taken   from   different 
investigators: 

As  the  table  shows,  the  longtli  of  male  children  continues  slightly  in 
excess  of  that  of  fcMualos,  the  ditforenct^s  at  the  end  of  the  j-ear  equalling 
about  1  cm.  (0.4  inch). 


'Lelub.  (I.  KiiidcMli.,  1<)11,  I,  8. 


30 


THE  DISEASES  OF  CHILDREN 


Table  9. — Gain  in  Length  in  Boys  and  Girls 
(Heubner) 


Boys 


Girls 


Birth 

1  month .  . 

2  months . 

3  months . 

4  months . 

5  months . 

6  months . 

7  months . 

8  months . 

9  months . 

10  months 

11  months 

12  months 


51.0  cm. 

52.5  cm. 
55.3  cm. 
57.8  cm. 

60.1  cm. 
61.3  cm. 

62.6  cm. 
64.6  cm. 
65.6  cm. 
67.8  cm. 
67.0  cm. 
69.0  cm. 
70.3  cm. 


(20.1  in.) 

(20.7  in.) 
(21.8  in.) 
(22.7  in.) 
(23.7  in.) 
(24.1  in.) 
(24.6  in.) 
(25.4  in.) 
(25.8  in.) 
(26.7  in.) 
(26.4  in.) 
(27.2  in.) 
(27.7  in.) 


49.0  cm. 
51.3  cm. 
54.8  cm. 
56.7  cm. 
58.7  cm. 
60.2  cm. 
61.5  cm. 

63.2  cm. 

64.3  cm. 

65.4  cm. 
67.2  cm. 

68.1  cm. 

69.2  cm. 


(19.3  in.) 
(20.2  in.) 
(21.6  in.) 
(22.3  in.) 
(23.1  in.) 
(23.7  in.) 
(24.2  in.) 
(24.9  in.) 
(25.3  in.) 
(25.8  in.) 
(26.5  in.) 
(26.8  in.) 
(27.2  in.) 


During  the  periods  covered  by  the  ages  from  1  to  5  years  the  gain  in 
the  2d  year  of  life  is  about  10  cm.  (3.9  inches);  in  the  3d,  9  cm.  (3.5 
inches)  and  in  the  4th  and  5th  years  7  cm.  (2.8  inches).  The  following 
figures  show  this  in  tabular  form,  assuming  the  length  at  1  year  to 
be  28  inches  (71  cm.) : 

Table  10. — Gain  in  Length  in  the  First  Five  Years 

1  year 28. 0    in.  (71    cm.) 

2  years 32.0    in.  (81    cm.) 

3  years 35 . 5    in.  (90    cm.) 

4  years 38.25  in.  (97    cm.) 

5  years 41.0    in.  (104  cm.) 

The  studies  of  Freeman^  upon  278  well-cared-for  children  in  private 
practice  showed  a  length  for  the  first  5  years  decidedly  above  these 
figures.  This  depends  doubtless  on  the  patients  being  of  a  better  social 
class. 

During  this  period  the  difference  in  length  between  the  sexes  con- 
tinues, but  does  not  increase. 

From  the  age  of  5  years  onward  the  combined  rate  of  increase  in  the 
two  sexes  is  about  2  inches  (5  cm.)  a  year  until  the  age  of  11  years,  after 
which  girls  slightly  exceed  boys  in  height  until  the  age  of  15  years,  when 
boys  again  take  the  lead.  Increase  in  length  is  very  slight  in  girls  after 
they  reach  16  years.  The  length  at  bir-t,h  is  doubled  between  the  ages 
of  4  and  5  years  and  trebled  at  about  13  or  14  years. 

The  following  table  shows  the  gain  in  height  in  boys  and  girls  re- 
spectively, according  to  the  extensive  observations  of  Bowditch,^  Porter,^ 
Peckham'*  and  Variot  and  Chaumet.^  Very  similar  statistics  in  both 
height  and  weight  are  given  by  Tuxford  and  Glegg.^ 

Growth  in  length  exhibits  certain  definite  seasonal  relationships, 
analogous  to,  though  differing  from,  those  affecting  that  in  weight. 
The  greatest  increase  in  length,  according  to  the  studies  of  Schmidt- 
Monard^  in  children  from  2  to  13  years,  takes  place  in  July  and  August, 

1  Amer.  Jour.  Dis.  Child.,  1914,  VIII,  321. 

2  Loc.  cit. 
'  Loc.  cit. 
■•  Loc.  cit. 

6  Bui.  soe.  de  ped.  de  Paris,  1.90B,  Feb.,  53. 

6  Brit.  Med.  Jour.,  1911,  I,  1423. 

'  Jahrb.  f.  Kinderheilk.,  1895,  XL,  84. 


DEVELOPMENT 


31 


and  the  least  from  September  to 
influenced  by  illness  than  that  in 
often  unduly  short. 

As  with  weight,  the  season 
of  the  year  at  which  birth  takes 
place  would  appear  to  influence 
the  later  growth  in  length,  the 
longest  school  children  among 
those  studied  by  Stepanoff^ 
being  those  born  in  the  summer. 

Relation  in  Length  of  the  Head, 
Trunk  and  Extremities. — In  the 
new  born  the  lower  portion  of 
the  body,  measured  from  the 
level  of  the  iliac  crest,  is,  accord- 
ing to  the  figures  of  Zeising,^ 
about  equal  to  the  upper  portion 
in  length,  while  in  adults  it 
measures  62  to  63  per  cent,  of 
the  total.  It  is  this  which  makes 
the  infant's  legs  appear  so  short. 
Later  the  lower  portion  grows 
more  rapidly,  but  it  is  not  until 
near  puberty  that  its  rate  of 
growth  becomes  markedly 
greater  than  that  of  the  upper. 
The  head  in  the  new  born, 
measured  from  the  vertex  to  the 
larynx,  is  very  long,  about  25 
per  cent,  of  the  total  body- 
length,  against  about  11  per 
cent,  in  the  adult  (Hoffmann).^ 
The  proportionate  length  of  the 
upper  extremities  does  not  alter 
materially  with  increase  in  years. 
The  comparison  of  the  length  of 
the  different  parts  of  the  body  is 
well  shown  in  the  accompany- 
ing diagram  (Fig.  7).  The  in- 
fluence of  sex  is  somewhat  ap- 
parent. According  to  the 
studies  of  Peckham*  the  length 
of  the  trunk  of  the  girl  is  less 
than  that  of  the  boy  until  about 
the  age  of  9  years,  after  which, 
until  the  age  of  15,  it  is  greater. 

*  Loc.  cit. 

^  Nova  Acta  Acad.  Caes.  Leop. 
Carol,  natur.  curios.,  1858,  XXVI,  2, 
783.  Ref.  Vierordt,  Datenu.  Tabellon, 
1906,  30,  31. 

'  Ref.  Vierordt,  Datcn  u.  TabellDn, 
1906,  15. 

^  Sixth  Ann.  Rep.  Wisconsin  State 
Board  of  Health,  1881,  60. 


February.     Increase  in  length  is  less 
weight,  although  rachitic  children  are 


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■^32 


THE  DISEASES  OF  CHILDREN 


On  the  other  hand  while  the  legs  of  the  girl  at  9  years  are  longer  than 
those  of  the  boy,  the  boy  much  surpasses  her  later  in  length  of  leg.  In 
fact,  girls  increase  very  Httle  in  length  of  leg  after  the  age  of  14  or  15 
years,  while  boys  grow  both  in  legs  and  trunk. 

General  Surface. — By  the  age  of  2  weeks  the  dark-red  color  of  the 
skin  of  the  body  has  changed  to  the  rose-pink  characteristic  of  infancy. 
Generally  by  the  end  of  the  first  week  or  earher  any  lanugo  remaining 
begins  to  fall,  and  this  is  accompanied  by  a  more  or  less  extensive  shedding 
of  the  epidermis,  sometimes  in  small  scales,  sometimes  in  large  flakes. 
This  shedding  lasts  from  2  to  3  weeks.  The  sudoriparous  glands  are  not 
very  active  in  the  first  4  weeks  of  life  in  healthy  children.  Very  soon, 
however,  they  secrete  well  and  the  insensible  and  even  sensible  per- 
spiration is  considerable,  although  free  perspiration  normally  does  not 
occur  for  several  months. 


Birth  2  years  6  years  15  years  25  years 

Fig.  7. — Growth-propohtions  at  Different  Life-periods. 
Showing  the  length  of  different  portions  of  the  body  as  compared  with  the  head  at 
different  periods  of  life.     At  birth  the   body  is  4  heads  high,  while  in  the  adult  it  is  8 
heads  high.      (After  Slratz,  Der  Korper  des  KindC-i',  1904,  64,  Fig.  42.) 

Head.  Size  and  Shape. — The  circumference  of  the  head  at  birth 
averages  about  13  to  13^^  inches  (33  to  35  cm.).  The  measurement  in 
new-born  girls  is  from  0.2  to  0.4  inch  (0.5  to  1  cm.)  less  than  in  boys. 
Growth  is  at  first  rapid,  but  is  very  slow  after  the  age  of  5  years.  Pub- 
lished statistics  vary  considerably,  but  a  comparison  of  a  number  of 
investigations  gives  the  following  average  figures  of  the  circumference 
at  birth  and  of  the  increase: 

Table  12. — Circumference  op  the  Head 

Birth 33  to  35  cm.  (13.0  to  13.8  in.) 

6  months 42  to  45  cm.  (16.5  to  17.7  in.) 

1  year 45  to  46  cm.  (17.7  to  18.1  in.) 

2  years 47  to  48  cm.  (18.5  to  18.9  in.) 

3  years 48.5  to  50  cm.  (19.1  to  19.7  in.) 

4  years 50  to  52  cm.  (19.7  to  20.5  in.) 

5  years .52  to  53  cm.  (20.5  to  20.9  in.) 

Adult 53  to  55  cm.  (20 . 9  to  21 . 7  in.) 


DEVELOPMENT 


33 


It  will  be  noticed  that  the  growth  in  circumference  is  about  10  cm. 
(3.9  inches)  during  the  1st  year,  which  is  approximately  one-half  of  the 
increase  of  the  child  in  length.     In  the  2d  year  the  increase  is  about 

2  cm.  (0.8  inch).     Girls  gradually  fall  behind  to  the  amount  of  Ij-^  to 

3  cm.  (0.6  to  1.2  inches)  in  the  circumference  of  the  head. 

The  sha'pe  of  the  head  differs  decidedly  in  infants  from  that  in  adult 
life  (Fig.  8) .  The  facial  portion  is  small  as  compared  with  the  cranial ; 
the  ratio  of  the  respective  dimensions  in  the  new  born  being  1  : 8  and  in  the 
adult  1:2  or  2^  (Froriep).^  Its  rate  of  growth  is,  however,  more  rapid 
(Weissenberg).^     The  caput  succedaneum,  i.e.,  the  swelling  of  the  scalp 


(o^  (6) 

Fig.  8. — Comparison  of  Skulls. 
Of  the  infant  (a)  and  of  the  adult  (5).     {After  Henke,  GerhardVs  Handb.  d.  Kinderkr., 
I,  248;  249.) 

resulting  from  pressure  during  labor,  generally  disappears  by  the  10th  day 
or  earlier  (see  p.  271.) 

Owing  to  the  yielding  nature  of  the  bones  of  the  skull  and  the  absence 
of  union  of  the  sutures  the  shape  may  be  altered  by  long-continued 
pressure  as  by  that  during  labor,  or  by  the  child  lying  too  much  upon  the 
back  or  side,  thus  flattening  the  occiput  or  one  of  the  parietal  regions. 
This  distortion  is  usually  only  of  temporary  duration. 

Fontanelles. — The  posterior  fontanelle  can  be  felt  open  until  the  age 
of  6  or  8  weeks.  The  anterior,  of  rhomboidal  shape,  increases  in  size 
according  to  the  views  of  most  observers  until  the  Dth  month,  owing  to 

*  Die  Characteristik  des  Kopfes  nach  dem  Entwickelungsgesezte  desselben.  Bed., 
1845.     Ref.  Henke,  Gerhardt's  Handb.  d.  Kinderkr.,  1877,  I,  250. 
2  Jahrb.  f.  lunderh.,  1908,  LXVIII,  316. 
3 


34  THE  DISEASES  OF  CHILDREN 

the  fact  that  the  brain  grows  faster  than  the  bones  covering  it.  By  the 
12th  month  it  should  be  decidedly  smaller.  According  to  Kassowitz/ 
however,  it  should  grow  steadily  smaller  from  the  time  of  birth,  and  any 
increase  in  its  size  must  be  attributed  to  rickets.  The  fontanelle  should 
be.  closed  by  the  age  of  17  or  18  months.  Even  in  healthy  children  it 
sometimes  closes  earlier  or  remains  open  longer  than  the  average  time 
allows,  but  closure  should  be  accomplished  by  2  years  at  the  latest. 
It  is  slightly  larger  in  boys,  and  in  the  children  of  primiparse  (Fehling).^ 
There  are  great  variations  in  the  size  of  the  anterior  fontanelle  at  birth, 
and  in  the  statements  made  regarding  this.  A  diameter  ranging  from 
2  to  21^^  cm.  (0.8  to  1  inch)  between  the  parallel  sides  perhaps  expresses 
the  average.  Elsasser^  gives  the  following  figures  for  the  changes  which 
take  place  with  time : 

Table  13. — Size  op  Anterior  Fontanelle 
(Elsasser)'* 

1  to  3  months 2.51  cm.  (1 .0  in.) 

4  to  6  months 3.12  cm.  (1.2  in.) 

7  to  9  months 3 .  63  cm.  (1 . 4  in.) 

10  to  12  months 3.11  cm.  (1.2  in.) 

13  to  15  months 2.03  cm.  (0.8  in.) 

Scalp. — Although  the  scalp  at  birth  frequently  shows  only  short 
sparse  hair  it  is  often  covered  with  a  thick,  rather  dark,  comparatively 
long  growth,  measuring  from  13^^  to  2  inches  (3.8  to  5.1  cm.).  This 
begins  to  fall  at  the  end  of  the  first  week  and  generally  leaves  the  head 
almost  bald,  although  some  stays  on  much  longer  than  this,  and  many 
infants  retain  a  heavy  growth  of  hair  for  months.  The  new  hair  comes 
in  only  slowly,  and  is  of  firmer  texture  and  generally  lighter  color.  Unless 
precautions  are  taken  a  collection  of  oily  scales  very  rapidly  accumulates 
on  the  scalp. 

Eyes. — The  eyes  at  birth  and  in  the  first  weeks  of  life  are  kept  shut 
or  half  open  and  are  largel}^  devoid  of  expression.  Their  color  is  a 
somewhat  indefinite  blue-gray,  which  only  later  changes  into  the  per- 
manent hue  of  the  iris,  varying  in  different  subjects.  The  movements. of 
the  eyes  are  largely  incoordinated.  Tears  are  usually  not  shed  until 
the  age  of  3  or  4  months. 

Ears. — The  meatus  is  not  fully  developed  at  birth,  the  portion 
finally  osseous  not  becoming  so  until  the  4th  year.  The  direction  of 
the  meatus  is  inward  and  downward  and  the  tympanic  membrane  is 
horizontal  or  inclined  slightly  upward.  The  tympanic  cavity  is  devoid 
of  air  at  birth  and  contains  only  swollen  mucous  membrane  and  mucus. 
The  nose  of  the  new  born  is  relatively  small  and,  as  a  whole,  situated 
higher  in  the  face  than  in  adult  life.  The  maxillary  antrum  and  ethmoidal 
cells  are  present  at  birth;  the  other  sinuses  develop  later  (Coffin). ^  The 
fat  in  the  cheeks  is  comparatively  well  developed,  and  forms  in  each  what 
is  called  the  "sucking-cushion."  The  jaws  are  small  and  in  a  rudimen- 
tary condition  at  birth.  The  angle  of  the  ranuis  and  body  of  the  lower 
jaw  is  much   more  obtuse  than  later  in  life.     During  infancy  the  jaws 

1  Verhandl.  d.  deutsch.  Gesellsch.  f.  Kinderheilk.,  Strassburg,  1885. 

2  Arch.  f.  Gynak.,  1875,  VII,  575. 

^  Die  vveiche  Kinderkopf,  1843,  10. 

*  I  have  used  the  metric  equivalents  for  Elsasser's  statistics  as  given  by  Vierordt 
(Daten  und  Tabellen,  1906,  104).     The  original  is  in  "the  old  Parisian  lines"   (p.  9), 
^Amer.  Jour.  Med.  Sci.,  1905,  CXXIX,  302. 


DEVELOPMENT  35 

grow  considerably,  but  especially  in  later  childhood  they  enlarge  in 
order  to  admit  the  permanent  molar  teeth. 

Spine. — The  spinal  column  of  the  new  born  is  of  such  flexibility 
that  the  existence  of  any  of  the  natural  curves  of  later  life  is  doubtful. 
The  sacrococcygeal  curve  is  present,  it  is  true,  but  the  remainder  of  the 
spine  either  forms  one  long  continuation  of  this  or  is  straight.  Syming- 
ton^ has  pointed  out  that  the  neck,  as  compared  with  the  rest  of  the  spinal 
column,  is  in  reality  relatively  longer  than  in  adult  life,  about  equalling 
the  lumbar  portion.  Its  apparent  shortness  is  due  to  the  large  amount 
of  fat  covering  it,  and  to  the  high  position  of  the  sternum.  The  curve 
in  the  neck,  with  the  convexity  forward,  does  not  appear  until  the  child 
begins  to  hold  its  head  erect,  and  never  becomes  fixed.  Still  later,  when 
the  child  learns  to  stand  and  walk,  a  similar  curve  forms  in  the  lumbar  re- 
gion and  one  with  the  concavity  forward  in  the  dorsal  region.  The  lum- 
bar spine  grows  faster  than  the  other  portions  until  a  Uttle  after  puberty. 

Thorax. — The  chest  in  infancy  is  small  as  compared  with  the  abdo- 
men and  with  the  thoracic  development  of  later  life.  The  combination 
of  small  chest  and  large  abdomen,  together  with  the  high  position  of 
the  narrow  and  insignificant  shoulder-girdle,  gives  the  trunk  a  peculiar 
barrel-shaped  appearance.  The  nipples  are  small  and  are  situated  in 
the  4th  interspace  or  over  the  4th  rib  as  in  adult  life. 

The  ribs  are  more  horizontally  placed  than  in  adult  life  and  the  false 
ribs  particularly  project  upward  to  a  greater  extent.  The  diaphragm 
extends  somewhat  higher,  and  the  sternum  is  relatively  smaller  than  in 
adult  life.  The  upper  border  of  the  manubrium  of  the  sternum  stands 
higher  than  later  while  the  lower  projects  more  sharply  forward. 

Whereas  in  adults  the  transverse  diameter  of  the  thorax  is  to  the 
anteroposterior  as  2  :1  (Fetzer),^  or  3  : 1  (Symington)^  in  the  new  born 
the  diameters  according  to  Eckerlein^  are  nearly  equal,  the  transverse 
being  to  the  antero-posterior  as  3  :2.  As  a  result  the  horizontal  section 
of  the  thorax  in  early  infancy  appears  nearly  circular,  while  that  of  the 
adult  is  elliptical.  The  transverse  diameter  grows  more  rapidh^  than 
the  other,  and  the  adult  shape  of  the  chest  is  present  to  a  large  degree 
by  the  beginning  of  childhood. 

There  is  considerable  diversity  in  the  estimates  of  different  investi- 
gators regarding  the  circumference  of  the  chest  at  birth  taken  at  the  height 
of  the  nipples,  and  the  rate  of  growth  in  the  first  5  years  of  life.  This 
depends  upon  the  great  variation  to  which  this  growth  is  susceptible, 
rendering  any  statistics  only  average  ones.  Approximate  figures,  the 
average  obtained  from  the  statistics  of  a  number  of  authors,  read  as 
follows : 

Table  14. — Growth  of  Chest  in  the  First  Five  Years 

Birth 32  to  33  cm.  (12 . 6  to  13 . 0  in.) 

6  months 41  to  42  cm.  (l(i.  1  to  1G.5  in.) 

1  year 44  to  46  cm.  (17.3  to  18. 1  in.) 

2  years 45  to  48  cm.  (17.7  to  18.9  in.) 

3  years 50  to  51  cm.  (19.7  to  20.1  in.) 

4  years 52  to  53  cm.  (20.5  to  20.9  in.) 

5  years 54  to  56  cm.  (21.3  to  22 . 0  in.) 

1  Anatomy  of  the  Child,  1887. 

^  Ueber  die  Einfiuss  d.  MiUtardienstes  auf  d.  Korpcrentwickehing,  1879,  198;  Ref. 
Vierordt's  Daten  u.  Tabellen,  1906,  98. 
'  Anat.  of  the  Child,  1887. 
*  Zeitsch.  f.  Geburtsh.  u.  Gyn.,  1890,  XIX,  120. 


36 


THE  DISEASES  OF  CHILDREN 


In  female  children  the  circumference  is  from  0.5  to  1.5  cm.  (0.2  to 
0.6  inch)  less  than  in  male. 

The  difference  in  the  rate  of  growth  of  the  thorax  in  each  sex  after 
the  age  of  5  years  up  to  that  of  18  years  is  illustrated  by  the  observations 
of  Porter^  in  over  34,000  measurements  of  school  children  in  St.  Louis, 
Mo.,  and  given  in  the  following  table: 

T.\BLE  15. — Growth  op  Chest  in  Boys  and  Girls 


Chest 

Boys 

Girls 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

17 

18 

59.05  cm.  (23.2  in.) 
60.62  cm.  (23.9  in.) 
62.18  cm.  (24.5  in.) 
63.90  cm    (25.2  in.) 
65.59  cm.  (25.8  in.) 
67.24  cm.  (26.5  in.) 
68.76  cm.  (27.1  in.) 
70.61  cm.  (27.8  in.) 
73.27  cm.  (28.9  in.) 
76.56  cm.  (30.1  in.) 
79.22  cm.  (31.2  in.) 
81.39  cm.  (32.0  in.) 
84.52  cm.  (33.3  in.) 

58.34  cm.  (23.0  in.) 
59.47  cm.  (23.4  in.) 
60.81cm.  (23.9  in.) 
62.51  cm.  (24.5  in.) 
63.02  cm.  (24.8  in.) 
65.85  cm.  (25.9  in.) 
68.34  cm.  (26.9  in.) 
71.29  cm.  (28.1  in.) 
74.13  cm.  (29.2  in.) 
76.78  cm.  (30.6  in.) 
78.85  cm.  (31.0  in.) 
80.39  cm.  (31.7  in.) 
80.45  cm.  (31.7  in.) 

According  to  the  observations  of  Monti'  the  average  increase  in  cir- 
cumference in  the  1st  year  is  12  cm.  (4.7  inches)  in  the  2d  year  3  cm.  (1.2 
inches)  and  in  the  remaining  years  up  to  12,  1.25  cm.  (0.5  inch).  There 
then  occurs  a  sudden  increase  in  the  rate  of  growth,  averaging  4  cm.  (1.57 
inches)  a  year. 

The  comparison  of  the  rate  of  growth  in  the  circumference  of  the 
chest  and  of  the  head  respectively  is  of  great  practical  utility.  The 
combination  of  the  two  tables  already  presented  (pp.  32  and  35)  gives 
the  following  results : 

Table  16. — Comparison  of  Circumferences  of  the  Head  and  Chest 


Head 


Chest 


Birth 

6  montLs. 

1  year ... 

2  years . 

3  years . 

4  years . 


33-35  cm.  (13.0  to  13r8  in.) 
42-45  cm.  (16.5  to  17.7  in.) 
45-46  cm.  (17.7  to  18.1  in.) 
47-48  cm.  (18.5  to  18.9  in.) 
48.5-50  cm.  (19.1  to  19.7  in.) 
50-52  cm.  (19.7  to  20.5  in.) 
5  years 52-53  cm.  (20.5  to  20.8  in.) 


32-33  cm.  (12.6  to  13.0  in.) 
41-42  cm.  (16.1  to  16.5  in.) 
44-46  cm.  (17.3  to  18.1  in.) 
45-48  cm.  (17.7  to  18.9  in.) 
50-51  cm.  (19.7  to  20.1  in.) 
52-53  cm.  (20.5  to  20.9  in.) 
54-56  cm.  (21.3  to  22.0  in.) 


This  relationship  is,  however,  open  to  considerable  variation.  The 
chest  often  grows  quite  rapidly,  its  circumference  equalling  that  of  the 
head  by  the  age  of  1  year.  Still  Frobelius'*  has  found  from  a  large  number  of 
measurements,  that  the  circumference  of  the  chest  at  birth  should  never 
be  over  2  to  2.5  cm.  (0.8  to  1  inch)  less  than  that  of  the  head,  and  that 

1  Transac.  Acad.  Science  St.  Louis,  VI,  No.  12,  354. 
^  Kinderheilk.  in  Einzeldarst,  1899,  I,  565. 
3  St.  Petersb.  med.  Zeitsch.,  1873,  IV,  363. 


DIGESTIVE  APPARATUS  37 

in  proportion  as  these  figures  are  exceeded  the  mortaUty  is  much 
increased.  It  is  certainly  a  sign  of  feeble  development  when  the  cir- 
cumference of  the  chest  has  not  exceeded  that  of  the  head  by  the  age  of 
3  years. 

Abdomen. — The  abdomen  appears  relatively  large  and  prominent 
in  infancy,  depending  in  part  upon  the  large  size  of  the  Uver,  in  part  on 
the  great  amount  of  subcutaneous  fat  present,  and  in  part  on  the  small 
size  of  the  pelvis  and  of  the  chest.  Its  circumference  measures  about  the 
same  as  that  of  the  chest  up  to  2  years  after  which  period  it  is  decidedly 
less.  The  stump  of  the  umbilical  cord  remaining  after  birth  gradually 
shrivels,  exhibiting  a  small  red  area  around  it  at  its  junction  with  the  body. 
About  the  4th  to  the  6th  day  the  stump  falls,  leaving  an  ulcer  which  heals 
rapidly,  closing  after  5  to  6  days.  The  umbilicus  occupies  nearly  the 
central  part  of  the  body  during  the  first  2  years.  In  adult  life  its  distance 
above  the  soles  is  %  of  the  total  length  of  the  body. 

Pelvis. — The  pelvis  in  the  infant  is  very  small  and  more  obliquely 
situated  than  later.  According  to  Liharzik,i  the  width  of  the  body  at 
the  hips  at  all  ages  equals  that  of  the  shoulders  in  males,  but  the  hips  are 
always  wider  than  the  shoulders  in  females. 

Limbs.^ — The  bowing  of  the  short  legs  present  at  birth,  which  depends 
upon  an  actual  curve  in  the  bone,  persists  until  during  the  2d  year. 
The  tendency  to  hold  the  arms  and  legs  in  the  fetal  position  (p.  3  9), 
with  the  feet  dorsally  flexed,  is  exhibited  more  ot  less  during  the  early 
months.  Although  infants  are  seemingly  flat-footed,  in  reality  the  feet 
are  shaped  much  as  in  adult  life,  the  shortness  and  thickness  seen 
especially  in  later  infancy  depending  in  reality  upon  the  large  amount 
of  fat  in  the  subcutaneous  tissue. 

DIGESTIVE  APPARATUS 

Mouth. — The  mouth  in  early  infancy  is  comparatively  dry  with  the 
tongue  also  drier  than  later  and  generally  with  a  whitish  coating.  The 
jaws  at  birth  will  not  meet.  They  are  covered  with  gums  of  a  pale-red 
color,  and  exhibit  rather  hard  narrow  opposing  ridges.  No  signs  of  the 
presence  of  teeth  are  visible. 

Dentition. — The  20  temporary  teeth,  also  called  deciduous,  first,  or 
milk  teeth,  that  appear  later  are  at  birth  enclosed  in  dental  folhcles, 
and  in  alveoli  in  the  jaw  which  are  already  osseous  in  nature.  The 
crowns  of  the  incisor  teeth  are  even  then  entirely  calcified,  as  are  those 
of  the  other  teeth  to  a  considerable  extent.  The  teeth  and  tooth-sacs 
are  covered  only  by  mucous  membrane  and  sub-mucous  connective 
tissue,  and  the  alveoli  are  broad  and  allow  of  free  growth.  As  calcifica- 
tion and  elongation  of  the  roots  take  place,  the  crowns  are  gradually 
forced  onward  in  the  direction  of  least  resistance.  Under  this  constant 
pressure  outward  the  gums  covering  them  atrophy,  flatten  and  grow 
paler,  and  the  teeth  finally  push  through.  Probably  the  only  resistance 
offered  has  come  from  the  sub-nmcous  tissue.  Complete  calcification  of 
the  fangs  is  not  present  when  the  teeth  appear,  and  does  not  occur  until 
the  child  is  several  years  of  age. 

The  germs  of  the  permanent  teeth,  or  second  teeth,  except  the  second 
and  third  molars,  are  already  present  in  the  gums  at  birth,  resting  against 

^Das  Gesetz  des  Wachsthums,  etc.,  1862;  Ref.  Vierordt's  Daten  u.  Tabellen, 
1906,  30. 


38  THE  DISEASES  OF  CHILDREN 

the  posterior  walls  of  the  dental  sacs  of  the  temporary  teeth.  The 
crowns  of  the  anterior  molars  are  calcified.  In  the  other  teeth  of  this 
set  the  calcification  begins  at  different  periods  between  the  first  and  the 
eighth  year.  Like  the  first  set  they  increase  in  length,  their  eruption 
depending  principally  upon  the  calcification  of  the  roots.  Probably  from 
insufficient  supply  of  blood,  occasioned  by  pressure  of  the  advancing 
permanent  teeth,  the  roots  of  the  temporary  set  finally  undergo  absorp- 
tion and  the  teeth  drop  out  in  much  the  same  order  as  they  came  in. 
Eruption  of  the  Temporary  Teeth  (Fig.  9). — Many  different  state- 
ments have  been  made  by  authors  regarding  the  time  of  the  eruption  of 
the  20  temporary  teeth.  The  following  table  expresses  a  very  generally 
accepted  view.  It  will  be  noticed  that  the  teeth  erupt  in  distinct  groups, 
with  a  period  between  each  group. 

Table  17. — Eruption  of  the  Temporary  Teeth 

*  First  Group 2  lower  central  incisors 7  months 

Pause 3  to  8  weeks.       Total  2. 

Second  Group 4  upper  incisors 8  to  10  months 

Pause 1  to  3  months.     Total  6. 

Third  Group 4  anterior  molars  and  2  lower  lateral  incisors ...    12  to  15  months 

Pause 2  to  3  months.     Total  12. 

Fourth  Group 4  canines 18  to  24  months 

Pause 2  to  4  months.     Total  16. 

Fifth  Group 4  posterior  molars 20  to  30  months 

Total  20. 


The  upper  and  lower  canines  are  popularly  called  the  "eye-teeth"  and 
the  "stomach  teeth"  respectively.     In  the  third  group  the  lower  lateral 

incisors  appear,  according  to  many  obser- 
vers, before  the  molars,  but  ihei;e  is  no 
absolute  rule  for  this.  In  fact  the  whole 
table  represents  only  the  order  of  eruption 
very  frequently  seen,  and  it  is  certain  that 
there  may  be  an  extremely  wide  variation 
within  physiological  limits.  The  age  of  7 
months  may  be  considered  the  average 
time  of  appearance  of  the  first  tooth,  yet 

^'°'  ^t^upoIIry  T^l^r^^  ™^     ^"^  ^"^^  "^^  exceeding  the  1st  year  may 
^,    !"  .  ^  ',  ,     ,     be  called  normal.     From  6  to  8  months  is 

o,  central    incisors;    b,  lateral  -,  ,  •  ,    r, 

incisors;  c,  canines;  d,  anterior     ^  Very  coiiimon  range,  and  eruption  at  3 
molars;  e,  posterior  molars.  OF  4  months  IS  not  at  all  Uncommon. 

In  perfectly  normal  states  the  eruption 
of  the  teeth  is  unattended  by  any  symptoms  whatever.  The  patho- 
logical conditions  which  are  believed  to  develop  will  be  considered"  in 
the  section  upon  Disorders  of  Dentition  (p.  651). 

Eruption  of  the  Permanent  Teeth  (Fig.  10).- — The  permanent  teeth, 
or  teeth  of  the  second  dentition,  arc  32  in  number.  The  earliest  to  be  cut 
are  the  first  molars,  which  come  in  just  posterior  to  the  temporary  second 
molars.  They  appear  at  about  the  age  of  6  years  and  are  consequently 
often  called  the  "6-year-old  molars."  The  other  teeth  erupt  in  much 
the  same  order  as  those  of  the  temporary  set.  Although  the  order  and 
dates  of  appearing  are  subject  to  considerable  variation,  the  following 
table  is  a  fair  expression  of  them : 


DIGESTIVE  APPARATUS 


39 


Table  18. — Eruption  of  the  Permanent  Teeth 

First  molars 6  years 

Central  incisors 7  years 

Lateral  incisors 8  years 

First  bicuspids 9  years 

Second  bicuspids 10  years  ' 

Canines 11  to  13  years 

Second  molars 12  to  15  years 

Third  molars  (Wisdom  teeth) 17  to  25  years 

a  a 

b     J ^.<-^     h 


Fig.   10. — Diagram  Showing  the  Permanent  Teeth. 
a,  central  incisors;  b,  lateral  incisors;  c,  canines;  d,  first  bicuspids;  e,  second  bicuspids; 
/,  first  molars;  g,  second  molars;  h,  third  molars. 

The  teeth  of  the  lower  jaw  usually  erupt  somewhat  before  the  cor- 
responding ones  of  the  upper  jaw,  the  interval  being  often  as  much  as 
several  months.  It  will  be  observed  that  the  permanent  molars  do  not 
replace  any  of  the  temporary  teeth,  but  constitute  12  new  teeth  addi- 
tional to  the  [original  20.     The  bicuspids  replace  the  temporary  molars 


Fig.  11. — .Jaws  of  Child  About  7  Years  Old,  Showing  Temporary  and  Permanent 

Sets  of  Teeth,  Except  the  Wisdom  Teeth. 

(McClellan,  in  Keating's  Cyclopedia  of  the  Diseases  of  Children,  1889,  /,  18,  Fig.  12). 

and  the  canines  and  incisors  the  corresponding  teeth  of  the  first  set. 
The  bicuspids  are  smaller  than  the  temporary  molars,  and  the  perma- 
nent incisors  larger  than  those  which  preceded  them.  At  about  the 
age  of  6  years  the  jaws  contain  all  the  teeth  of  both  sets,  visible  or 
concealed,  except  the  third  permanent  molars  (Fig.  11). 


40 


THE  DISEASES  OF  CHILDREN 


Salivary  Glands. — The  comparatively  small  amount  of  saliva  se- 
creted by  the  new  born  accounts  for  the  dryness  of  the  mouth  and  the 
coating  of  the  tongue  referred  to.  By  the  2d  month  increase  in  the 
secretion  begins  and  by  the  age  of  3  or  4  months  this  is  still  further 
augmented  and  the  child  begins  to  "dribble."  This  increase  takes 
place,  as  a  rule,  before  the  eruption  of  teeth,  and  appears  to  be  in  no  way 
connected  with  it.  Although  according  to  the  investigations  of  Korowin^ 
and  of  ZweifeP  ptyalin  is  present  in  the  salivary  glands  even  at  birth, 
any  diastasic*  activity  is  inconsiderable  until  the  increased  secretion  of 
saliva  begins.  Even  then,  since  much  of  the  fluid  runs  out  of  the  mouth, 
its  influence  upon  digestion  is  probably  not  great.  As  the  first  year 
advances  the  amount  of  saliva  grows  greater  and  by  about  the  age  of  1 
year  its  diastasic  power  is  about  as  great  as  in  adult  life  (Finizio).^ 

Esophagus. — The  total  length  of  the  esophagus  in  the  new  born, 
according  to  the  statistics  collected  by  Vierordt,^  is  about  10  cm.  (3.9 
inches)  or,  including  the  total  distance  from  the  teeth  to  the  cardiac 
orifice,  17  cm.  (6.7  inches).  This  latter  distance  at  the  age  of  3  years  is 
30  cm.  (11.8  inches)  and  in  adult  life  40  cm.  (15.8  inches).  The  pseudo- 
valvular  opening  at  the  gastric  end  of  the  esophagus  is  stated  by  Gub- 
aroff^  to  be  imperfectly  developed  in  infancy.  This  accounts  in  part  for 
the  greater  ease  with  which  vomiting  occurs  at  this  time  of  life. 

Stomach. — The  capacity  of  the  stomach  varies  greatly  in  different 
infants  within  normal  limits,  as  is  shown  by  the  results  obtained  by  differ- 
ent observers.  This  is  illustrated  in  the  following  table  from  which, 
however,  an  idea  of  the  approximate  size  may  be  obtained: 


Table  19. — Capacity  of 

THE  Stomach  at 

Different 

Periods 

K 

Fleisch- 
mann* 

Holt' 

Frolowskys 

Pflaunder» 

Benekei" 

Co. 

Fl.oz. 

C.c. 

Fl.oz. 

C.c. 

Fl.oz. 

C.c. 

Fl.oz. 

Co. 

Fl.oz. 

Birth 

i!6 

2.4 

36 

'44 
59 
100 
133 
148 
176 

263 

1.2 

1.5' 

2.0 

3.37 

4.50 

5.00 

5.75 

8.9' 

'56 
70 
112 
158 
167 
178 

1.7 
2.4 
3.8 
5.3 
5.6 
6.4 

. 
'96 

100 
110 
125 
160 

3^6 
3.4 
3.7 
4.2 
5.4 

35-43 
153-160 

740 

1.2-1.5 

1  week 

46 

7*^ 

2  weeks            ... 

5.2-5.4 

1  month 

2  months 

3  months 

4  months 

6  months 

80 
140 

2.7 

4.7 

9  months 

2S3     8.6 

225  1    7.6 
290     9.8 

1  year 

2  years 

25 

*  The  original  tables  vary  slightly  from  this,  the  data  being  for  the  number  of 
weeks  rather  than  of  months.  As  the  differences,  however,  are  inconsiderable,  I  have 
purposely  distorted  the  figures  slightly  to  apply  to  the  age  in  months. 

'  Centralb  f.  d.  med.  Wissensch.,  1873,  XI,  261. 

2  Untersuch.  u.  d.  Verdaungsapparat  der.  Neugeb.,  1874. 

3  Rev.  d'hvg.  et  de  m&l.  inf.,  1909,  VIII,  224. 

*  Daten  u.  Tabellen,  1906,  112. 

^  Arch.  f.  Anat.  u.  Entwickelungsgeschichte,  1886,  395.  Ref.  Jacobi,  Keating's 
Cyclop,  of  the  Dis.  of  Child.,  1889,  I,  35. 

6  Klinik  d.  Pjidiatrik,  1875,  I. 

7  Arch,  of  Fed.,  1890,  963. 

«  St.  Petersb.  Dissertation,  1876.  Ref.  Vierordt,  Daten  u.  Tabellen,  1906,  115. 
»  Wien.  klin.  Wochenschr.,  1897,  No.  44. 
10  Deut.  med.  Wochenschr.,  1880,  VI,  448. 


DIGESTIVE  APPARATUS  41 

Roughly  we  may  estimate  the  capacity  of  the  stomach  at  birth  at 
13^  fl.oz.  (37),  at  l"^month  as  2}-^  fl.oz.  (74),  at  6  months  as  5  fl.  oz.  (148), 
and  at  1  year  as  9^  fl.oz.  (288).  It  depends,  however,  on  the  size  of 
the  child  as  much  as  or  more  than  on  the  age  alone.  This  must  always 
be  taken  into  consideration  in  determining  the  amount  of  food  required 
by  an  infant  of  a  certain  age.  On  the  other  hand,  it  is  also  true  that  an 
infant  not  infrequently  can  digest,  and  requires,  a  larger  amount  of  food 
than  its  age  would  indicate.  This  may  well  be  because  some  of  the 
liquid  taken  passes  into  the  intestine  before  the  meal  is  completed. 
Basing  the  dietetic  requirements  upon  the  estimated  size  of  the  stomach 
is  consequently  a  procedure  to  be  depended  upon  only  with  limitations. 
The  capacity  in  artificially  fed  infants  is  somewhat  greater  than  in 
those  fed  at  the  breast.  The  orifice  of  the  pylorus  measures  2  cm. 
(0.78  inch)  in  circumference  in  the  new  born,  according  to  Pflaunder.^ 
The  position  of  the  stomach  early  in  infancy  had  been  generally  con- 
sidered to  be  nearly  vertical  or  slightly  oblique,  and  the  form  cjdin- 
drical;  but  the  more  recent  investigations  are  not  entirely  in  accord 
with  this.  Flesch  and  Peteri-  found  it  nearly  horizontal  in  the  1st  year 
of  life,  but  becoming  more  vertical  after  this  period.  Smith^  believes  it 
to  be  not  vertically  situated,  but  rather  obliquely,  and  Pisek  and 
LeWald^  showed  that  the  organ  changes  its  size  and  shape  from  time  to 
time,  depending  upon  the  amount  of  food  contained  in  it.  It  is  oftener 
horizontally  situated  rather  than  vertically,  and  the  pylorus  generally 
occupies  a  comparatively  high  and  anterior  position.  The  amount  of 
gastric  secretion  is  large  in  infancy.  Pepsin,  rennin  and  h3^drochloric  acid 
are  present  at  all  periods,  although  the  amount  of  rennin  and  of  acid 
occurring  in  the  new  born  is  proportionately  much  less  than  in  adult  life 
(Leo).^  The  amount,  however,  rapidly  increases  as  the  infant  grows 
older.  According  to  Langendorf^  pepsin  is  found  in  the  fetus  even  as 
early  as  the  4th  month  of  intra-uterine  life.  It  is  possible  that  rennin 
is  not  a  substance  distinct  from  pepsin.  A  fat-splitting  ferment  is  also 
present,  as  demonstrated  by  Sedgwick^  and  others;  and  Ibrahim  and 
Kopec^  found  it  in  the  6-months'  fetus. 

Liver. — The  liver  at  birth  is  hyperemic  and  large  and  its  edge  can 
be  distinctly  felt  below  the  costal  margin.  To  a  great  extent  it  covers 
the  anterior  and  outer  surface  of  the  stomach.  It  continues  to  extend 
below  the  costal  margin  until  about  the  age  of  5  years.  The  area  of 
hepatic  dullness  is  also  greater  in  early  life,  the  upper  margin  of  this 
reaching  the  4th  rib.  According  to  the  statistics  collected  by  Vierordt^ 
its  absolute  weight  averages  141.7  grams  (5  oz.)  in  the  male  and  164 
grams  (5.8  oz.)  in  the  female;  i.e.,  4.5  per  cent,  and  5.5  per  cent,  of  the 
body-weight,  while  in  the  adult  it  is  but  from  2.8  per  cent,  to  3  per  cent. 
The  weight  increases  little  or  none  during  the  first  6  months,  and,  in 
fact,  diminishes  slightly  in  the  first  weeks.     Kowalski's'"  figures,  however, 

'  IJeber  Magencapacitat,  etc.,  Bibliotheca  medica,  1898,  35. 
2Zeit.  f.  Kinderh.,  Grip;.,  1911,  II,  203. 
3  Arch,  of  Fed.,  1914,  XXXI,  781. 
*  Amer.  .Jour.  Dis.  Child.,  1913,  VI,  232. 
6  Berl.  klin.  Wochenschr.,  1888,  931. 
«  Arch.  f.  PhvsioloK.,  1879,  95. 
'  Arch,  of  Pod.,  190(5,  XXIII,  414. 
«  Zcitsch.  f.  Biol.,  1910,  LIII,  201. 
»  Arch.  f.  Anat.  11.  Physiol.,  Su])|)l.  Band,  1890,  62. 

'"  Dissert.  St.  PetersI).,  1908,  21.  Ref.  Morse  and  Talbot,  Diseases  of  Nutrition 
and  Infant  Feeding,  1915,  15. 


42  THE  DISEASES  OF  CHILDREN 

do  not  show  this  failure  to  increase  in  weight  in  the  early  months.  Bile 
is  secreted  even  before  birth.  The  investigations  of  Jacubowitsch'  indi- 
cate that  the  bile  of  the  infant  differs  from  that  of  the  adult  especially 
in  the  larger  proportion  of  water  and  the  smaller  amount  of  biliary  acids 
and  of  bile-salts  present,  and  the  consequent  lesser  power  of  digesting  the 
fats. 

Pancreas. — ^The  pancreas  at  birth  weighs  3.5  grams  (0.12  oz.)  (Vie- 
rordt),^  bearing  about  the  same  relation  to  the  body- weight  as  in  adult 
life.  Its  secretion  has  the  power  of  digesting  fat  in  early  infancy,  but 
not  to  the  degree  possessed  later.  The  diastatic  power  (amylopsin)  was 
claimed  by  Korowin^  to  be  absent  during  the  first  3  weeks,  feeble  after 
this,  and  not  to  attain  its  full  power  until  about  the  end  of  the  1st  year; 
but  Hess*  by  the  use  of  the  duodenal  tube  found  it  present  in  the  new  born, 
although  not  in  large  amount,  thus  confirming  the  observation  of  Ibra- 
him,^ who  obtained  it  in  a  6-months'  fetus.  It  would  appear  to  increase 
more  rapidly  in  power  than  formerly  supposed.  The  peptonizing  func- 
tion (trypsin)  is  active  in  the  1st  month  (Zweifel).^  Langendorf^  showed 
its  presence  in  the  fetus  of  5  months. 

Intestine. — The  total  length  of  the  small  intestine  in  the  new  born 
would  appear  from  Vierordt's^  statistics  to  vary  considerably,  ranging  from 
2  to  3.5  metres  (6.4  to  11.5 feet).  The  large  intestine  according  to  the  same 
authority  measures  from  0.42  to  0.48  metres  (1.38  to  1.57  feet).  The 
relative  length  of  the  bowel  as  compared  with  that  of  the  body  is  greater 
in  children  than  in  adults.  The  small  intestine  grows  rapidly.  Beneke^ 
found  it  at  birth  5^4  times  the  body  length,  at  2  years  about  6^  times,  at 
7  years  5  times,  and  in  adult  life  but  about  43^^  times.  The  large  intes- 
tine was  about  equal  in  length  to  that  of  the  body,  both  in  the  new  born 
and  in  the  adult.  The  sigmoid  flexure  is  especially  long  in  infants,  being 
at  birth,  as  stated  by  Treves, ^°  almost  equal  to  3^^  the  total  length  of 
the  large  intestine.  It  often  forms  a  huge  loop  running  up  to  the  lower 
border  of  the  liver.  It  is  perhaps  partly  due  to  this  abnormal  length 
that  constipation  occurs  so  frequently  in  infancy.  During  the  first  4 
months  the  sigmoid  diminishes  greatly  in  length,  while  the  rest  of  the 
colon  proportionately  increases,  the  total  length  of  the  large  intestine 
thus  remaining  unchanged.  The  vermiform  appendix  reaches  its  full 
length  early  in  life.  It  is  particularly  prone  to  kinking  in  infancy  and 
childhood,  and  is  abundantly  supplied  with  adenoid  tissue,  both  factors 
tending  to  the  production  of  appendicitis.  According  to  the  conclusions 
of  Gundobin^^  Beyer's  patches  are  well  developed,  but  less  numerous  in 
the  new  born  as  compared  with  adults;  the  number  of  solitary  follicles 
greater;  Lieberklihn's  follicles  and  the  villi  more  abundant;  and  Brun- 
ner's  glands  numerous  but  not  completely  developed.  The  muscular 
strength  of  the  intestine  is  comparatively  feeble.  Amylolytic  ferments 
are  present  in  the  small  intestine  from  birth. 

1  Jahrb.  f.  Kinderheilk.,  1886,  XXIV,  377. 

2  Daten  u.  Tabellen,  1906,  44. 

'  Centralb.  f.  d.  med.  Wissenschaft.  1873,  261. 

'  Amer.  Jour.  Dis.  Child.,  1912,  IV,  205. 

s  Verhandl.  d.  Gesellsch.  f.  Kinderh.,  1908,  XXV,  31. 

^  Untersuch.  ii.  d.  Verdaungsapparat.  d.  Neugeboren.,  1874. 

'  Arch.  f.  Anat.  u.  Physiol.,  1879,  95. 

«  Daten  u.  Tabellen,  1906,  117. 

9  Deutsch.  mod.  Wochenschr.,  1880,  VI,  433. 
'*•  Hunterian  Lectures,  1885,  10. 
11  Jahrb.  f.  Kinderh.,  1892,  XXXIII,  439. 


DIGESTION  IN  INFANCY  43 

DIGESTION  IN  INFANCY 

(See  also  Absorption  and  Metabolism,  p.  48) 

The  act  of  sucking  has  a  pump-Hke  quaUty.  The  base  of  the  nipple 
is  seized  firmly  by  the  infant's  lips;  the  tongue  is  pressed  against  the 
nipple,  making  a  longitudinal  gutter  in  which  it  may  lie,  and  along  which 
the  milk  is  conducted  backward ;  the  soft  palate  and  base  of  the  tongue 
approach  each  other  and  shut  off  the  posterior  opening  of  the  oral  cavity 
from  the  nose;  the  cheeks  sink  in  slightly,  while  the  lower  jaw  is  depressed, 
thus  producing  a  partial  vacuum,  by  means  of  which  the  milk  is  drawn 
from  the  breast.  The  sucking  cushions  already  referred  to  (see  Cheeks, 
p.  34)  are  supposed  to  prevent  a  too  great  collapse  of  the  cheeks.  To 
nurse  satisfactorily  the  infant  must  be  able  to  breathe  easily  through  the 
nose,  respiration  through  it  not  being  interfered  with  by  sucking,  although 
it  ceases  momentarily  during  the  act  of  swallowing. 

The  saliva  plays  but  small  part  in  digestion  in  early  infancy.  Later 
its  diastasic  action  is  of  service  in  the  case  of  infants  receiving  starch. 
Yet  this  action  is,  however,  not  completed  in  the  mouth,  and,  after  the 
food  is  swallowed,  should  continue  only  so  long  as  the  gastric  contents  are 
alkaline  or  but  faintly  acid,  which  is  but  for  a  short  time. 

The  stomach  is  more  of  a  simple  receptacle  in  infancy  than  is  the  case 
later  in  life.  Some  of  the  milk  entering  the  stomach  passes  immediatelj- 
through  the  pylorus  (Hess).^  That  remaining  is  promptly  coagulated  by 
the  action  of  the  rennin  or  by  the  hydrochloric  acid  present.  Tobler^ 
found  that  the  coagulation  commenced  in  2  or  3  minutes  after  the  milk 
was  ingested.  The  protein  of  human  milk  forms  small,  loose  curds;  that 
of  cow's  milk  a  much  firmer,  larger  mass.  This  may  be  due  to  the  larger 
percentage  of  protein  present  in  cow's  milk.  The  acidity  of  the  gastric 
contents  begins  very  soon  after  the  ingestion  of  food,  and  steadily  in- 
creases. Van  Puteren^  found  an  acid  reaction  after  10  minutes,  and  Leo^ 
after  15  minutes.  Yet  as  the  hydrochloric  acid  as  fast  as  secreted  unites 
with  the  elements  of  the  milk,  it  is  only  toward  the  end  of  gastric  diges- 
tion that  free  hydrochloric  acid  can  be  obtained  in  small  amount,  and 
generally  not  at  all.  The  degree  of  acidity  in  infants  is  decidedly  less 
than  in  adult  life.  Bauer  and  Deutsche  believed  lactic  acid  to  be  the 
predominant  one  after  the  ingestion  of  food  during  the  1st  half-year; 
and  Heiman^  found  it  in  half  of  the  breast-fed  infants  examined.  Other 
investigators,  as  Scdziuk,^  state  that  lactic  acid  is  seldom  found  in  the 
stomach  of  the  health}^  breast-fed  infant.  Butyric  acid  develops  in  the 
stomach  only  in  pathological  conditions  when  the  amount  of  hydrochloric 
acid  is  diminished.  The  acidity  of  the  gastric  contents  seems  to  depend 
in  large  part  upon  phosphoric  acid  and  its  salts. 

After  the  milk  has  been  coagulated  its  solution  by  the  pepsin  begins, 
the  hydrochloric  acid  now  aiding  in  accomplishing  this.  Yet  nmch 
the  greater  portion  of  the  coagulated  milk  passes  out  of  the  stomach  of  the 
infant  but  little  affected  in  other  respects  by  gastric  digestion.     There  is 

>  Amer.  Jour.  Dis.  Child.,  1914,  VII,  428. 

2  Verhandl.  der  Gesellsch.  f.  Ivinderh.,  1906,  XXIII,  144. 

'  Ueber  die  Verdaung  der  Saugekindcr  in  der  ersten  zwei  Lebensraonaton.  Ar- 
beitcn  der  Gesellsch.  f.  Kinderarzte  in  St.  Petersburg,  1889.  Ref.  Bauer  and  Deutsch, 
Jahrb.  f.  Kindeih.,  1898,  XLVIII,  27;  68. 

*  Borl.  klin.  Wochenschr.,  1888,  XXV,  981. 

6  Jahrb.  f.  Kinderh.,  1898.  XLVIII,  22. 

«  Arch,  of  Ped.,  1910,  XX.VII,  570. 

'  Przegl.  Pedyat.,  1913,  V,  14.     Ref.  Arch.  f.  Kinderh.,  1914,  LXIII,  271. 


44  THE  DISEASES  OF  CHILDREN 

no  action  exerted  by  the  gastric  secretion  upon  the  carbohydrate,  al- 
though the  fat  is  acted  upon  to  some  extent  by  the  hpase  of  the  stomach. 

The  length  of  time  during  which  the  ingested  food  remains  in  the 
infant's  stomach  probably  varies  with  the  infant.  Leo^  found  that  a 
considerable  portion  of  the  milk  had  left  the  stomach  within  j^  hour,  the 
liquid  portion  containing  the  sugar  and  salts  and  the  uncoagulated  milk 
passing  out  first,  and  that  in  the  1st  week  of  life  the  organ  would  some- 
times be  empty  within  1  hour,  and  in  the  1st  month  generally  within 
13^^  hours.  This  is  confirmed  bj^  Clark. '^  Later  a  somewhat  longer 
time  is  required,  but  the  average  health}^  breast-fed  infant  retains  but 
little  of  the  food  in  the  stomach  longer  than  at  most  2  or  2^2  hours. 
This  has  been  practically  confirmed  radiologically  by  Leven  and  Barret,' 
Tobler  and  Bogen,"*  Flesch  and  Peteri,^  Ladd,''  Pisek  and  LeWald^  and 
others.  The  cardiac  orifice  of  the  stomach,  as  proven  by  the  experi- 
ments of  Cannon^  on  animals,  closes  automatically  with  a  certain  degree 
of  normal  acidity  of  the  gastric  contents.  The  pyloric  orifice,  on  the 
other  hand,  as  shown  by  Cowie  and  Lyon^  for  infants,  opens  when  a 
certain  degree  of  acidity  is  attained.  The  nature  of  the  food  taken  influ- 
ences the  time  it  remains  in  the  stomach.  Human  milk  passes  from  it 
more  rapidly  than  cow's  milk.  The  greater  the  amount  of  casein,  the 
longer  the  continuance  of  the  food  in  the  stomach.  This  fact,  previ- 
ously accepted,  was  demonstrated  radiologically  bj^  Ladd.  ^''  Delay  also 
depends  to  a  large  extent  upon  the  amount  of  fat  present  (Tobler).'' 
DeBuys  and  Henriques'^  demonstrated  that  the  body-posture  has  much 
to  do  with  the  rapidity  of  the  emptying  of  the  stomach,  the  rapidity 
be'ng  greatest  in  the  right  lateral  position.  The  stomach  is  of  little 
service  in  the  absorption  of  food,  but  a  small  amount  of  the  sugar  and 
digested  protein  being  taken  up  here;  the  fats,  water  and  salts  practi- 
cally not  at  all. 

In  the  intestine  the  trypsin  of  the  pancreatic  juice  accomplishes  the 
peptonizing  of  the  milk  not  already  digested  in  the  stomach;  this  being 
probably,  as  stated,  much  the  larger  part.  If  the  contents  of  the  stomach 
are  expelled  from  it  in  a  hyperacid  state  no  peptonizing  by  the  trypsin 
takes  place,  since  this  ferment  requires  the  presence  of  an  alkaline  reaction, 
and  is,  in  fact,  destroyed  by  acidity  of  the  gastric  secretion.  Inasmuch  as 
the  saliva  is  in  such  small  amount  in  early  infancy  and  the  diastatic 
ferment  of  the  pancreas  is  not  secreted  to  any  considerable  extent  in  the 
1st  month,  the  power  of  digesting  any  starchy  food  at  this  period  of  hfe 
would  appear  to  be  very  limited.  It  must  be  stated,  however,  that  investi- 
gations by  Heubner,  '^  Carstens,^"*  Shaw  '^  and  others  apparently  prove  that 
even  infants  of  2  months  possess  a  decided  power  to  digest  starch.     The 

1  Loc.  cit. 

2  Arch,  of  Fed.,  1911,  XXVIII,  648. 

3  Presse  m(5dicale,  1906,  XIV.  503. 

'  Monatsschr.  f.  ICinderh.,  1908,  VII,  12. 

6  Zcit.  f.  Kinderh.,  Orig.,  1911,  II,  263. 

«  Amer.  Jour.  Dis.  Child.,  1913,  V,  345. 

'  Amer.  .Jour.  Dis.  Child.,  1913,  VI.  232. 

*  Amer.  Jour.  Physiol.,  1908,  XXIII,  105. 

9  Amer.  Jour.  Dis.  Child.,  1911,  II,  252. 
10  Arch,  of  Ped.,  1913,  XXX,  740. 
1'  Ergebnisse  der  inn.  Med.  u.  Kinderh..  1908,  I,  514. 
>2Amer.  .Jmir.  Dis.  Child.,  1918,  XV,  190. 
"  Berlin,  klin.  Wochenschr.,  1895,  201. 
"  Berlin,  klin.  Wochenschr.,  1895,  1100. 

"  Albany  Med.  Annals,  1904,  XXV,  148. 


DIGESTION  IN  INFANCY  45 

bile-salts  in  infancy  in  combination  with  the  steapsin  of  the  pancreas 
split  the  fat,  and  permit  of  saponification  and  the  forming  of  an  emulsion. 
The  secretion  of  the  small  intestine  converts  the  various  sugars  into  the 
monosaccharides;  galactose,  levulose  and  dextrose. 

The  peristalsis  of  infancy  is  less  active  than  in  later  childhood  or 
adult  life,  and  the  combination  of  this  condition  with  the  unusual  rela- 
tive length  of  the  intestine  probably  gives  the  infant  an  especial  ability  to 
digest  and  absorb  the  large  amount  of  milk  taken.  Independently  of 
this,  the  infant  possesses  a  very  active  power  of  absorption.  This  takes 
place  principally  from  the  small  intestine,  whence  all  the  elements  of  the 
food  enter  the  system,  the  fat  passing  in  practically  only  from  this  region. 
The  large  intestine  absorbs  all;  but  to  a  very  limited  degree. 

Bacteria  of  the  Qastro=intestinal  Tract. — Mouth. — A  considera- 
ble number  of  species  of  bacteria  appear  in  the  mouth  even  very  soon 
after  birth,  and  with  the  beginning  of  the  taking  of  food  increases 
decidedly.  With  the  appearance  of  the  teeth  there  is  a  further  increase 
in  the  number  of  varieties.  Among  those  oftenest  found  by  Nobecourt 
and  de  Vicaris^  are  the  bacillus  lactis  aerogenes,  micrococcus  candidans, 
bacillus  coli,  micrococcus  pyogenes  aureus  and  albus,  and  the  strepto- 
coccus pyogenes  and  salivaris. 

Stomach. — The  number  of  bacteria  found  normally  in  the  stomach  is 
limited,  the  hydrochloric  acid  having  destroyed  many  of  those  swallowed 
with  the  food.  Yet  there  are  many  contained  within  the  masses  of  coagu- 
lated milk,  which  the  acid  cannot  affect  (Tobler).^ 

Intestine. — The  healthy  normal  infant  exhibits  soon  after  birth  a 
considerable  number  of  species  of  bacteria  in  this  region.  The  subject 
was  originally  investigated  especially  by  Escherich,''  and  in  more  recent 
years  by  Tissier,^  Moro^  and  others.  After  breast-feeding  commences 
the  number  of  germs  increases  greatly,  although  the  varieties  are  not 
numerous.  In  general  the  most  prominent  bacteria  in  the  intestinal 
tract  in  breast-fed  infants  are  the  bacillus  bifidus  (Tissier),  the  bacillus 
acidophilus  (^loro),  and  to  a  less  degree  the  bacillus  coli  and  the  bacillus 
lactis  aerogenes.  There  are  also  sometimes  present  the  bacillus  perfrin- 
gens,  bacillus  butyricus,  micrococcus  ovalis,  streptococci,  and  certain 
others  in  smaller  numbers.  The  upper  part  of  the  small  intestine  ex- 
hibits very  few  germs  of  any  sort.  The  bacillus  lactis  aerogenes  and  the 
colon  bacillus  in  small  numbers  are  those  chiefly  found.  The  former  is 
more  abundant  here  than  in  any  other  portion  of  the  intestinal  canal. 
The  lower  part  of  the  ileum  and  the  colon  contain  an  abundant  growth 
of  bacteria,  the  bacillus  bifidus  being  the  predominating  germ.  There  are 
also  present  the  bacillus  acidophilus,  the  colon  bacillus,  the  micrococcus 
ovalis,  and  a  diminished  number  of  the  bacillus  lactis  aerogenes.  The 
colon  and  rectum  have  a  smaller  number  of  living  bacteria  than  is  found 
in  the  cecum. 

In  artificially  fed  infants  the  variety  of  germs  is  greatly  increased. 
The  colon  bacillus  and  intestinal  cocci  are  the  predominating  micro- 
organisms, but  the  others  mentioned  arc  also  present  in  large  numi)ers. 
The  colon  bacillus  and  the  bacillus  lactis  aerogenes  are  more  numerous 

1  Arch.  g6n.  de  m(5d.,  1905,  CXCVI,  3201. 
^  Ergebnisso  d.  inn.  Med.  u.  Kindcrh.,  i'.)OS,  I,  495. 
^  Darmbakterien  des  S:iuglings,  18S0. 

*  Coinptes  rend.  soc.  de  l)iol.,  1899,  \'I.  943.  XIIL  Internal.  Med.  Cong.,  1900. 
M6d.  de  I'cnf,  20S. 

^.Jahil).  f.  Kindeih.,  1905,  LXI,  (iST;  870. 


46  THE  DISEASES  OF  CHILDREN 

than  in  breast-fed  children.  Bahrdt  and  Beifeld^  emphasize  the  fact 
that  in  the  breast-fed  infants  the  germs  are  especially  those  producing 
fermentation;  while  in  the  bottle-fed  the  process  is  chiefly  decomposition. 
The  bacilli  of  the  breast-fed  infants  tend  to  be  Gram-positive,  and  those 
of  the  artificially  fed  infants  Gram-negative. 

Under  pathological  conditions  there  may  be  an  enormous  increase  in 
the  number  of  the  normal  bacteria,  and  various  others  are  present,  not 
native  to  the  intestine ;  while  at  the  same  time  germs  which  are  normally 
present  and  harmless  assume  a  special  virulence  and  are  productive  of 
diseased  conditions.  Among  those  found  are  the  bacillus  proteus  vul- 
garis, bacillus  enteritidis,  streptococcus  enteritidis,  bacillus  pyocyaneus, 
and  forms  of  the  dysenterj^  bacillus. 

Gases  of  the  Digestive  Tract.- — The  gas  in  the  stomach  is  in  part 
swallowed  by  the  infant  while  nursing,  and  in  part  enters  from  the  intes- 
tine. But  little  is  produced  by  fermentation  of  the  food,  and  a  small 
quantity  appears  to  be  secreted  by  the  gastric  mucous  membrane.  In 
healthy  children  it  consists  of  the  elements  of  the  atmospheric  air  only. 

The  gas  in  the  intestine  depends  principally  on  the  decomposition  of 
the  milk-sugar  and  consists  of  COo  and  H  (Escherich).^  There  are  no 
foul-smelling  gases  in  the  intestine  of  milk-fed  infants  who  are  in  a 
healthy  condition. 

Feces. — The  first  passages  of  the  infant  consist  of  the  meconium. 
This  is  a  tarry,  dark,  greenish-brown,  almost  odorless  and  faintly  acid 
substance.  It  is  sometimes  passed  before  or  during  birth,  and  3  to  5 
times  during  the  first  2  or  3  days  of  life.  It  contains  cells  from  the  in- 
testine and  the  skin,  minute  hairs,  fatty  granules  and  globules,  cellular 
detritus,  intestinal  mucus,  and  biliary  acids,  coloring  matter,  cholesterin 
crystals  and  other  substances  derived  from  the  bile.  The  source  of 
some  of  the  elements  is  the  amniotic  liquid  which  the  fettis  has  swallowed 
from  time  to  time.  Vierordt^  estimates  the  total  amount  of  meconium 
passed  as  equalling  60  to  90  grams  (2,12  to  3.17  oz.).  Should,  the 
secretion  of  milk  be  delayed,  the  meconium  is  replaced  after  2  or  3 
days  by  stools  consisting  of  brownish  or  greenish  mucus.  On  the  3d 
or  4th  day,  or  sometimes  earlier  or  later,  the  ordinary  milk-feces  of  the 
infant  appear.  These  are  golden-yellow  or  canary-yellow  in  color,  of 
salve-like  consistence  or  of  that  of  thin  mush,  and  faintly  acid  in  odor 
and  reaction.  When  cow's  milk  is  the  food  employed  the  stools  are 
alkaline  (Biedert),"*  neutral  or  faintly  acid ;  of  a  paler  yellow  color,  have  a 
more  unpleasant  odor  due  to  the  decomposition  of  the  protein,  and  are 
often  more  consistent.  Thoroughly  digested  breast-milk  stools  appear 
almost  entirely  homogenous  (Fig.  12).  The  reaction  is,  however,  accord- 
ing to  Schlossmann"  not  necessarily  an  indication  of  the  health  of  the 
infant,  nor  is  it  dependent  upon  the  actual  amount  of  the  different  in- 
gredients in  the  food,  as  much  as  upon  the  relationship  between  them. 
A  ratio  of  3  to  1  between  the  fat  and  the  protein  produces  an  acid  stool, 
while  one  of  1  to  1  makes  the  stool  alkaline.  Consequently  the  alkaline 
reaction  of  the  stools  of  the  bottle-fed  infant  is  a  natural  result  of  the  com- 
paratively high  percentage  of  protein  as  compared  with  that  of  the  fat. 
Very  numerous  small  whitish  masses  are  very  common  in  the  stools  of 

1  Jahrb.  f.  Kinderh.,  1910,  LXXII,  Erganzungsh.,  71. 

2  Darmbakterien  des  Siiiiglings,  1886,  160. 

3  Gerhardt's  Handb.  d.  Kinderkrankh.,  1877,  1,  118. 
*  Die  Kinderernahrung  im  Sauglingsalter,  1900,  58. 

s  Centralbl.  f.  Kinderh.,  1906,  IX,  237. 


% 


Fig.  T2. — THOROff;iTi,Y  Digested  I^reast-mii.k  Stool. 


DIGESTION  IN  INFANCY  47 

infants  apparently  entirely  healthy  and  thriving;  and  this  is  especially 
true  of  those  artificially  fed.  A  brownish  color  may  depend  upon  a 
relatively  large  proportion  of  protein. 

The  number  of  intestinal  evacuations  is  at  first  from  2  to  4  in  24 
hours,  and  after  about  the  6th  week  and  up  to  the  age  of  2  years 
from  1  to  3.  There  may  be,  however,  considerable  variation  from  these 
figures  within  the  bounds  of  health.  The  amount  of  fecal  matter  passed 
is  estimated  by  Uffellmann^  to  be  about  3  per  cent,  of  the  milk  taken,  or, 
in  the  case  of  feeding  with  cow's  milk,  4.3  per  cent.;  averaging  3  grams 
per  kilo  (21  grains  per  lb.)  of  the  body- weight,  but  with  a  wide  range 
among  individual  cases. 

The  stools  contain  approximately  85  per  cent,  of  water  (85.13  per 
cent.  Wegschneider).^  The  greater  part  of  the  residue  consists  of  cellular 
elements,  mucus  and  bacteria.  The  milk  taken  is  never  wholly  absorbed. 
Fat  is  always  present  in  the  feces,  both  as  neutral  fat,  in  the  form  of  fatty 
acids,  and  as  soaps  from  combination  of  these  with  the  alkalies  and 
alkaline  earths.  With  potassium  and  sodium  an  excess  of  fat  forms 
soft,  white  curds;  with  calcium  and  magnesium  insoluble  soap-stools 
are  produced.  The  fat  forms  from  9  per  cent,  to  25  per  cent,  or  even 
more  of  the  dried  feces,  according  to  various  statistics  collected  by 
Biedert.^  The  amount  may  be  much  in  excess  of  this  when  the 
milk  is  especially  rich  in  this  element.  The  sugar  of  the  food  is  entirely 
absorbed.  Protein  is  present  only  in  very  small  amount  in  the  stools 
of  healthy  infants.  Knopfelmacher^  found  that  the  greater  portion 
of  the  nitrogen  and  phosphorus  recovered  from  the  feces  of  breast- 
fed infants  is  derived  from  the  digestive  secretions  and  not  from 
the  milk  ingested.  The  protein  of  this  latter  has  been  in  part 
absorbed,  in  part  broken  up  by  the  action  of  bacteria.  From  8 
to  10  per  cent,  of  the  dried  feces  consists  of  mineral  matter,  chiefly 
calcium,  derived  partly  from  the  food,  partly  secreted  by  the  in- 
testine. The  proportion  of  mineral  matter  is  higher  in  artificially  fed 
infants  (Blauberg),^  (Heubner).^  The  small,  whitish  masses  very  fre- 
quently present  in  the  bowel-movements  of  health}^,  thriving  children 
consist  principally  of  fat  or  its  derivatives  and  of  epithelial  cells.  The 
yellow  color  depends  upon  the  presence  of  bilirubin  which  is  present  un- 
changed in  part.  The  pale  greenish  tint  so  frequently  appearing  in  the 
stools  of  healthy  children  a  short  time  after  they  are  passed,  or  even 
present  at  first,  is  the  result  of  the  oxidation  of  biHrubin  to  biliverdin. 
The  acid  reaction  is  due  to  the  lactic  acid  and  the  fattj^  acids  present. 
Such  chemical  combinations  as  phenol  and  skatol,  which  give  the  charac- 
teristic odor  to  the  stools  of  adults,  are  not  found  in  those  of  milk-fed 
infants.  Various  ferments  are  present  in  the  feces,  among  them  diastase, 
lactase,  invertin,  trypsin,  rennin,  a  fat-splitting  ferment  and  others 
(Hecht).7 

Under  the  microscope  the  bowel-movements  of  the  infant  exhibit 
fat-globules  of  various  sizes;  some  molecular  fat;  needles  of  fatty  acids; 
innumerable  bacteria;  cholesterine  plates;  square  and  colunmar  epithelial 

1  Deutsch.  Arch.  f.  klin.  Med.,  1881,  XXVIII,  442. 

2  Ueber  die  norniale  Verdauung  bei  Siiuglinge,  1875.  Ref.  Vierordt,  Datcn  u. 
Tabellen,  190G,  300. 

^  Loc.  cil. ,  01. 

*  Jahrb.  f.  Kindorh.,  1900,  LII,  545. 

*  Zeit.  f.  Biol..  1900,  XL,  1;  30. 

8  Verhandl.  d.  Gcsell.sch.  f.  Kinderh.,  1901,  XVIII,  230. 
^  Die  Faeces  des  Siiuglings  und  des  Kindes,  1910,  14S. 


48  THE  DISEASES  OF  CHILDREN 

cells;  small  round  cells;  some  thin,  granular,  yellow,  flake-like  masses; 
lime-salts  in  crystalline  form,  and  occasionally  bilirubin  crystals,  yeast 
fungi,  and  proteid  matter. 

The  evacuations  become  a  somewhat  darker  yellow  as  the  infant 
grows  older,  and,  when  the  diet  is  more  varied,  and  especially  when 
the  amount  of  milk  is  relatively  diminished,  they  acquire  more  the  character- 
istics of  the  stools  of  adults,  both  in  color  and  odor.  They  are  still  soft, 
however,  as  a  rule,  and  acid  in  reaction.  It  is  only  at  about  the  age  of 
2  years  that  the  stools  become  formed.  This  is,  however,  open  to  many 
exceptions,  for  even  young  infants  may  normally  pass  fully  formed  stools. 

Bacteria  of  the  Feces. — The  meconium  is  at  first  sterile,  but  within 
24  hours  microorganisms  enter  by  the  mouth  and  anus,  although  not 
found  in  large  numbers.  After  breast-feeding  begins  they  are  very 
numerous,  but  not  in  great  variety.  In  fact  a  large  part  of  the  stools 
in  infancy  is  composed  of  bacteria.  Leschziner^  found  that  the  dried 
substance  of  the  normal  stool  of  breast-fed  infants  contains  from  2 
per  cent,  to  over  28  per  cent,  of  germs;  and  Strassburger^  obtained  as 
much  as  42.3  per  cent,  in  normal  stools  in  artificially  fed  children.  In 
the  normal  feces  of  the  breast-fed  infant  are  found  especially  the  bacil- 
lus'bifidus,  as  well  as  the  bacillus  coli,  bacillus  acidophilus,  butyric  acid 
bacillus  and  sometimes  the  bacillus  lactis  aerogenes  and  others.  In 
the  artificially  fed  infant  the  bacillus  bifidus  loses  its  predominance  and 
is  present  in  association  with  large  numbers  of  the  colon  bacillus,  bacillus 
acidophilus,  bacillus  lactis  aerogenes,  intestinal  cocci,  and  others,  no 
one  type  dominating  the  picture,  and  the  number  of  varieties  being  greater 
than  in  breast-fed  infants.  The  distinction  is  to  be  made  between  the 
fermentative  and  the  putrefactive  bacteria.  Germs  of  the  first  class, 
such  as  the  bacillus  bifidus  and  the  bacillus  lactis  aerogenes,  are  fer- 
mentative and  break  up  milk-sugar  into  lactic  acid  arid  gases,  giving 
an  acid  reaction  to  the  stool;  while  the  proteolytic  bacteria  produce, 
among  other  actions,  decomposition  of  the  protein  and  give  rise  to  an 
alkaline  reaction.  After  a  mixed  diet  is  commenced  there  is  a  further 
change  in  the  intestinal  flora,  with  an  increase  in  the  variety  of  the  micro- 
organisms in  the  stools. 

ABSORPTION  AND  METABOLISM  OF  THE  FOOD 

In  addition  to  and  summarizing  some  of  the  statements  already  made 
under  digestion  (p.  43)  a  brief  resume  may  be  given  of  the  physiological 
processes  which  attend  and  follow  this,  viewed  from  the  point  of  view 
of  the  food-elements  rather  than  the  organs  and  as  applicable  especially 
to  infancy.  A  very  large  amount  of  investigation  in  this  direction  has 
been  made  during  recent  years.  For  further  consideration  the  reader  is 
referred  to  the  numerous  journal  articles  upon  the  subject,  and  especially 
to  the  publications  of  Tobler  and  Bessau,^  Czerny  and  Keller,^  Langstein 
and  Meyer,^  and  Morse  and  Talbot.*^ 

Fat. — The  amount  of  fat  in  the  food  has  a  decided  influence  upon  the 
time  this  remains  in  the  stomach,  as  shown  by  the  investigations  of  Tobler, '^ 

1  Deutsch.  Aerzte-Zeitung,  1903,  V,  385. 
2^Zeit.  f.  klin.  Med.,  1902,  XLVI,  433. 

^  Briining  u.  Schwalbe,  Handb.  d.  allgern.  Path.  u.  d.  path.  Anat.  des  Kindes- 
alter,  1912,  I,  G.50. 

*  Des  Kindes  Ern:ihrung,  etc.,  1906. 
^  Sauglingserniihrung  u.  SiiugUngsstoffwechsel,  1914. 
^  Diseases  of  Nutrition  and  Infant  Feeding,  1915. 
'  Ergebnisse  der  inn.  Med.  u.  ffinderh.,  1908,  I,  514. 


ABSORPTION  AND  METABOLISM  OF  THE  FOOD  49 

the  larger  the  amount  of  this,  the  slower  being  its  discharge.  This  slow  en- 
trance into  the  small  intestine  permits  of  a  readier  digestion  of  it  when 
it  reaches  this  region.  The  fat  is  in  no  way  affected  by  the  saliva,  but 
in  the  stomach  the  gastric  lipase  is  able  to  break  up  a  considerable  por- 
tion of  it.  Comparatively  little  digestion  of  fat,  however,  occurs  here, 
and  no  absorption  at  all.  In  the  small  intestine  the  fat  is  split  by  the 
pancreatic  lipase  in  combination  with  the  bile-salts  and  aided  by  the  in- 
testinal secretion,  the  fatty  acids  uniting  with  the  alkalies  and  forming 
soaps,  soluble  and  insoluble,  and  later  an  emulsion.  It  is  in  this  form  that 
the  fat  is  absorbed  by  the  small  intestine,  more  than  90  per  cent,  of  that 
ingested  both  in  breast-fed  and  in  normal  bottle-fed  infants,  being  utilized. 
Very  little  fat  is  absorbed  by  the  large  intestine.  It  is  questionable 
whether  the  neutral  fat  as  it  occurs  in  the  milk  ingested  is  absorbed 
at  all  in  this  form.  There  is  reason  to  believe,  however,  as  claimed  by 
Kastle  and  Loevenhart^  that  the  lipase  in  the  intestinal  mucous  mem- 
brane may  change  the  soaps  back  into  neutral  fat  and  that  it  enters  the 
lacteals  in  this  form.  The  fat  appearing  in  the  stools  may  possibly 
be  derived  in  part  from  the  intestinal  secretion  and  from  decomposition 
of  the  carbohydrates ;  but  probably  much  the  largest  portion  is  from  the 
food.  The  absorption  of  fat  in  artificially  fed  infants  can  be  modified  by 
altering  the  proportion  of  the  other  elements  of  the  food.  Thus  in  some 
cases  an  addition  of  carbohydrate  apparently  increases  the  absorption 
of  the  fat  and  changes  a  soap-stool  to  one  of  a  more  normal  acid  character ; 
and,  on  the  other  hand,  an  increase  of  the  protein  may  similarly  change 
a  highly  acid,  loose  stool  into  a  firmer,  more  alkaline  one. 

In  the  economy  the  principle  purpose  of  the  fat  is  to  maintain  the 
body  heat.  It  is  an  element  of  the  food  which  it  is  very  difficult  to  do 
without  for  any  length  of  time,  for  since  its  caloric  value  is  twice  that 
of  either  protein  or  carbohydrate,  to  replace  it  an  undue  amount  of 
one  or  the  other  of  these  must  be  given. 

Carbohydrate.- — ^The  only  carbohydrate  present  in  milk  is  lactose ; 
a  disaccharide,  resolvable  into  dextrose  +  galactose  (Reuss).^  In  artifi- 
cially fed  infants  the  other  disaccharides,  saccharose  (dextrose  +  levulose) 
and  maltose  (dextrose  +  dextrose),  are  often  employed.  Starch,  too,  a 
polysaccharide,  is  to  be  considered,  and  in  older  children  cellulose.  On 
the  sugar  the  saliva  has  no  action  whatever,  nor  has  the  secretion  of  the 
pancreas,  unless  maltose  is  employed,  when  there  may  be  a  sHght  re- 
duction by  the  maltase  found  present  by  Ibrahim.^  The  starch  is  con- 
verted by  the  salivary,  pancreatic  and  intestinal  secretion  into  sugar; 
although  some  part  of  it  is  probably  destroyed  in  infancy  by  bacterial 
action  within  the  intestinal  canal.  The  power  of  digesting  starch  rapidly 
increases  with  an  increase  of  the  quantity  and  strength  of  the  amylolitic 
ferments.  The  invertin,  maltase  and  lactase  of  the  intestinal  canal  act 
respectively  upon  the  saccharose,  maltose  and  lactose,  reducing  them  to 
monosaccharides,  in  which  form  only  are  they  absorbable  under  ordinary 
conditions.  Only  when  given  in  very  large  amounts  do  the  disaccharides 
pass  the  normal  intestinal  mucous  membrane.  They  then  appear  un- 
changed in  the  urine,  with  the  exception  of  maltose,  which  may  l)e  broken 
up  by  the  maltase  of  the  blood  and  utilized.  The  monosaccharides 
are  absorbed  rapidly  by  the  small  intestine,  especially  in  the  upper  part, 
and  carried  b}^  the  portal  circulation  to  the  liver  where  they  are  changed 

1  Amer.  Chcm.  Joiir.,  1900,  XXIV,  491. 

2  Wien.  mcd.  Wochcnschr.,  1910,  LX,  103.5. 

3  Verhand.  d.  GescUsch.  f.  Kinderh.,  190S,  XXV,  [VI. 


50  THE  DISEASES  OF  CHILDREN 

into  glycogen.  The  large  intestine  also  possesses  to  some  extent  the 
power  of  the  reduction  of  the  disaccharides  and  of  absorption. 

The  different  sugars  are  utilized  by  the  infant  to  different  degrees. 
All  of  them  are  fermentable,  but  lactose  undergoes  lactic  acid  fermenta- 
tion, saccharose  more  readily  alcoholic  and  less  easily  butyric  acid  fer- 
mentation, and  maltose  most  easily  butyric  acid  and  next  readily 
alcoholic  fermentation.  Maltose  can  be  assimilated  in  larger  amount 
than  lactose;  the  latter  in  about  the  same  quantity  as  saccharose. 
Lactose  is  absorbed  more  slowly  than  the  others.  All  in  large  amount 
have  a  tendency  to  loosen  the  bowels  but  lactose  to  a  less  degree  than 
maltose.  The  normal  infant  can  digest  from  3.1  to  3.6  grams  of  lactose 
or  saccharose  per  kilogram  of  its  body-weight  (22  to  25  grains  per  lb.) 
and  about  7  grams  of  maltose  per  kilogram  (49  grains  per  lb.)  (Hill).^ 

The  assimilation,  or  at  least  the  retention,  of  the  nitrogen  of  the 
protein  is  rendered  more  complete  by  the  presence  of  carbohydrates,  as 
shown  by  Keller,^  Orgler^  and  others.  The  carbohydrates  would  seem, 
too,  when  not  in  excess  to  favor  the  absorption  of  fat,  perhaps  by  pre- 
venting the  formation  of  calcium  and  magnesium  soaps.  In  excess  they 
interfere  with  the  absorption  of  fat  by  producing  diarrhea,  by  which 
the  fat  and  the  other  intestinal  contents  are  rapidly  removed  from  the 
body.  After  absorption  the  carbohydrates  serve  to  maintain  the  heat 
of  the  body.  In  addition  they  have  an  action  in  preserving  the  proper 
metabolism  of  the  fats,  which  without  carbohydrates  are  productive  of 
acetone  bodies.  In  the  stools  the  carbohydrates  appear  chiefly  in  the 
form  of  undigested  starch,  when  this  is  given  in  unduly  large  amount  to 
infants.  Very  little  soluble  carbohydrate  is  found.  The  gas  in  the  intes- 
tine is  dependent  in  part  upon  the  decomposition  of  the  carbohydrate  by 
bacteria.  This  decomposition  also  produces  the  acidity  of  the  stools, 
which  is  in  direct  proportion  to  the  amount  of  the  carbohydrate  ingested. 

Protein. — The  digestion  of  the  protein  takes  place,  as  stated,  partly 
in  the  stomach,  under  the  influence  of  rennin,  pepsin  and  hydrochloric 
acid,  but  chiefly  in  the  intestine  by  the  trypsin  of  the  pancreas  and  the 
erepsin  of  the  intestinal  secretion.  The  action  of  this  latter  is  upon  the 
casein  and  the  peptones  and  albumoses,  changing  them  into  amino-acids, 
in  which  form  they  are  absorbed  and  utilized  in  the  body.  It  would  not 
appear  to  be  a  matter  of  indifference  in  what  form  the  protein  is  present 
in  the  food.  The  value  of  the  large  percentage  of  whey  in  human  milk 
may  depend  upon  the  fact  that  amino-acids  are  present  in  the  whey  in 
large  amount,  but  in  quite  small  quantity  in  the  casein.  There  is  almost 
complete  absorption  of  the  protein  in  normal  and  normally  fed  infants, 
the  dried  stools  showing  only  from  4  per  cent,  to  4.5  per  cent,  to  be 
nitrogen  (Orgler),*  and  even  this  is  chiefly  derived  from  the  intestinal 
secretions  and  from  dead  bacteria.  The  curds  in  the  stools  are  composed 
of  casein  to  a  very  limited  extent;  the  casein  curds  being  hard  and  tough, 
and  being  usually  absent  in  the  case  of  healthy  infants.  They  are  less 
liable  to  appear  when  the  milk  has  been  boiled  (Brennerman).^ 

The  needs  of  the  infant  in  the  matter  of  nitrogen  derived  from  the 
protein  are  not  great,  and  the  giving  of  an  excess  of  this  is  not  required. 
Whether  protein  is  capable  of  being  harmful  has  been  disputed.    Certainly 

1  Bost.  Med.  and  Surg.  Journ.,  1918,  CLXXIX,  1. 

2  Czerny  and  Keller,  he.  cit.,  1906,  I,  305. 

3  Jahrb.  f.  Kinderh.,  1908,  LXVII,  390. 

*  Ref.  Thiemich  in  Peer's  Lehrb.  d.  Kinderh.,  1914,  14. 
«  Amer.  Jour.  Dis.  Child.,  1911,  I,  341. 


ABSORPTION  AND  METABOLISM  OF  THE  FOOD  51 

it  can  usually  be  tolerated  in  large  amounts,  and  the  excess  is  then  utilized 
in  the  economy  for  the  production  of  calories.  (See  also  p.  130.)  At 
least  1.5  grams  per  kilogram  (10.5  grains  per  lb.)  of  the  body-weight 
is  required  daily  to  maintain  a  positive  nitrogen  balance  in  the  system; 
or  in  other  words  7  per  cent,  of  the  caloric  requirements  should  come 
from  the  protein.  This  is  approximately  equivalent  to  13^^  oz.  of  milk 
for  each  pound  of  the  weight  of  the  infant  (98  c.c.  per  kilo). 

Yet  the  maintaining  of  this  balance  does  not  depend  solely  upon  the 
amount  ingested.  Infants  may  retain  nitrogen  even  when  the  number 
of  calories  in  the  food  administered  is  insufficient.  While,  as  stated,  the 
giving  of  carbohydrate  in  proper  amount  favors  the  retention  of  nitrogen, 
the  fat  has  no  such  favorable  action,  and  in  excess  may  act  unfavorably. 
An  increase  in  the  retention  of  nitrogen  is  not  necessarily  attended  by  a 
gain  in  the  body- weight.  Inasmuch  as  all  proteins  must  be  reduced  to 
amino-acids  before  they  can  be  absorbed,  there  would  appear  to  be  no 
difference  in  the  effects  produced  by  them  in  entirely  healthy  infants, 
except,  as  stated,  in  the  greater  amount  of  amino-acids  present  in  some  of 
them,  and  the  consequent  less  digestive  action  required.  Yet  in  spite 
of  the  large  tolerance  for  protein  shown  by  most  children,  there  is  ample 
reason  to  beheve  that  these,  especially  as  seen  in  the  case  of  the  casein  of 
cow's  milk  given  in  excess,  are  capable  of  producing  decided  digestive 
disturbances.  This  has  been  emphasized  by  a  number  of  investigators. 
The  subject  is  reviewed,  among  others,  by  Benjamin^  and  by  Talbot  and 
Gamble.^     (See  also  p.  131.) 

Mineral  Matter. — The  salts  of  human  milk  (see  p.  97)  are  readily 
absorbed  from  the  small  intestine,  but  to  a  negligible  degree  from  other 
regions.  They  may  in  part  re-enter  the  intestine  from  the  circulation; 
and  in  addition  salts  are  contained  in  the  digestive  secretions.  Conse- 
quently, although  they  are  absolutely  necessary  for  digestion  and  metabo- 
lism, their  action  is  complicated  and  not  as  yet  thoroughly  understood. 
The  greater  quantity  of  salts,  except  iron,  in  cow's  milk  as  compared  with 
human  milk  results  in  the  amount  taken  by  the  infant  artificially  fed  being 
always  in  excess  of  the  needs.  In  general  the  absorption  and  retention  of 
the  mineral  matter  of  the  food  goes  hand  in  hand  with  that  of  the  nitrogen. 
Under  normal  conditions  40  per  cent,  of  the  mineral  of  the  ingested 
cow's  milk  is  lost  in  the  stools.  This  is  chiefly  calcium  phosphate  (Holt, 
Courtney,  and  Fales).^  The  presence  of  a  sufficient  amount  of  fat  in  the 
food  increases  the  retention  of  the  mineral  matter  (Hoobler).*  An  excess 
of  it  may  increase  the  loss  of  calcium  and  of  magnesium  in  the  feces  by 
the  production  of  soaps  in  large  amount.  Sodium  and  potassium  are 
absorbed  well  from  the  intestine.  They  are  eliminated  by  the  urine  and 
feces.  Phosphorus  is  absorbed  better  from  human  milk,  since  a  greater 
proportion  of  it  is  in  organic  combination  than  is  the  case  with  cow's 
milk.  According  to  Hoobler^  an  increase  of  the  fat  in  the  food  favors 
its  absorption.  The  retention  of  calcium  is  aided  by  carbohydrates,  un- 
less they  are  in  excess;  when  the  diarrhea  resulting  causes  a  decided  loss  of 
all  mineral  matter,  although  chiefly  the  potassium  and  sodium.  Calcium 
may  be  absorbed  either  from  organic  or  inorganic  combinations,  and  the 
part  of  it  which  is  not  retained  is  excreted  through  the  urine  or  through 

'  Zeitschr.  f.  Knderh.,  Orig.,  1914,  X,  185. 

2  Amer.  Jour.  Dis.  Child.,  1916,  XII,  333. 

3  Amer.  Jour.  Dis.  Child.,  1915,  IX,  213. 
*  Amer.  Jour.  Dis.  Child.,  1911,  II,  107. 

'  Loc.  cit. 


52  THE  DISEASES  OF  CHILDREN 

the  intestinal  wall  into  the  feces.  The  retention  of  magnesium  is,  accord- 
ing to  Hoobler^  better  when  the  fat-percentage  is  low.  With  all  these 
substances,  as  with  sulphur,  the  absorption  and  retention  appear  to  be 
better  in  infants  receiving  human  milk. 

GASEOUS  METABOLISM,  ENERGY  METABOLISM 

An  increasingly  large  amount  of  investigation  has  been  given  to  this 
subject  for  several  years.  Most  of  the  results  are  too  technical  for  in- 
clusion here,  and  but  a  brief  sketch  can  be  given  of  some  of  the  data 
obtained.  In  the  chapter  upon  Infant  Feeding  (p.  119)  reference  will  be 
again  made  to  the  direct  application  of  the  physiological  data  to  the  prep- 
aration of  the  food  for  an  artificially  fed  infant.  The  reader  is  referred 
to  the  journal-literature  which  will  be  mentioned,  and  especially  to  the 
chapter  upon  Energy  Metabolism  in  the  text-book  of  Morse  and  Talbot^ 
for  a  condensed  review  of  the  subject. 

Inasmuch  as  the  excretion  of  carbonic  dioxide  is,  as  shown  by  Rub- 
ner  and  Heubner,^  on  the  one  hand  in  proportion  to  the  body-surface, 
and,  on  the  other,  an  index  of  the  amount  of  nourishment  required,  it 
is  evident  that  the  number  of  calories  demanded  is  directly  related  to 
the  body-surface  of  the  infant.  Since,  however,  the  estimation  of  the 
surface  is  a  matter  difficult  or  impossible  to  compute  by  the  clinician, 
it  has  become  customary  to  make  the  weight  of  the  infant  the  basis.  This 
can  very  readily  lead  to  considerable  error,  inasmuch  as  it  is  possible  for 
an  infant  to  lose  many  pounds  of  its  body-weight,  and  yet  to  retain,  of 
course,  the  same  body-surface.  Further,  it  is  now  doubtful  whether  even 
the  body-surface  is  to  be  considered  the  guide,  but  rather  the  ''actual 
mass  of  the  protoplasmic  tissue"  (Benedict  and  Talbot).^ 

In  calculating  the  caloric  requirements  of  the  infant  it  may  be  reck- 
oned that  the  basal  metabolism  of  an  infant  of  any  age,  i.e.,  the  consump- 
tion of  energy  during  a  state  of  complete  repose  after  taking  food,  is 
equivalent  to  from  52  to  63  calories  per  kilogram  (24  to  29  calories  per 
pound)  of  the  body-weight.  This  constitutes  the  lowest  number  of 
calories  on  which  the  continuance  of  health  is  possible,  and  only  under 
this  condition  of  inactivitj^  and  does  not  allow  for  growth.  An  exception 
to  this  is  in  new-born  infants,  as  well  as  in  older  infants  decidedly  above 
the  average  weight  for  their  age.  Here  the  basal  metabolism  is  usually 
from  40  to  52  calories  per  kilogram  (18  to  24  calories  per  pound)  of  body- 
weight.  Muscular  exercise,  crying,  and  the  like  may  increase  the  energy- 
requirements  occasionally  as  much  as  100  per  cent  (Benedict  and  Tal- 
bot).^ The  sick  and  inactive  infant  produces  less  heat  than  the  healthy, 
lively  one.  The  former  ma}^  exhibit  no  greater  heat-production  than 
the  basal  metabolism ;  the  latter  decidedly  more.  The  new  born  requires 
a  minimum  of  fewer  calories  probably  on  account  of  this  inactivity;  and 
the  extra-fat  children  probably  partly  on  this  account  and  partly  because 
their  weight  is  out  of  proportion  to  their  body-surface.  Emaciated  in- 
fants have  a  basal  metabolism  above  the  figures  given,  vaiying  from  63 
to  87  calories  per  kilogram  (29  to  39  per  pound)  (Morse  and  Talbot). 

1  Loc.  cit. 

2  Diseases  of  Nutrition  and  Infant  Feeding,  191 5. 

3  Zeit.  f.  Biol.,  1898,  XXXVI,  1;  1889,  XXXVIII,  315. 

*  Amer.  Jour.  Dis.  Child.,  1914,  VIII,  1. 

*  Carnegie  Institute  Wash.,  Pub.  20i,  p.  97.     Ref.    Morse  and  Talbot,  Diseases 
of  Nutrition  and  Infant  Feeding,  1915,  58. 


ORGANS  OF  RESPIRATION  53 

This  is,  however,  provided  they  cry  considerably.     If  very  weak  and  quiet 
the  figures  are  not  so  high. 

Heubner^  determined  that  the  average  healthy  breast-fed  infant  in 
its  1st  half-year  required  100  large  calories  per  kilogram  (45  per  pound) 
of  body-weight  in  order  to  gain  properly,  the  number  diminishing  gradu- 
ally in  the  2d  half-year.  This  he  denominated  the  "energy-quotient." 
Premature  infants  and  those  under  3  months  artificially  fed  have  an 
energy-quotient  of  120  calories  (54  per  pound).  These  figures  have  been 
largely  followed  by  clinicians  in  determining  the  food-requirements  of 
infants.  They  are,  however,  far  from  being  universally  accepted. 
Cramer^  found  that  the  energy-quotient  for  the  new  born  was  less  than 
50  calories  (23  per  pound).  Czerny  and  Keller^  believe  Heubner's 
figures  too  high,  and  reported  an  instance  of  satisfactory  progress  on  an 
energy-quotient  of  70  (32  per  pound) ;  and  Ramsey  and  Alley*  came  to 
much  the  same  conclusion;  while  Ladd^  gives  from  93  to  159  calories  per 
kilogram  (42  to  72  calories  per  pound)  as  the  range  of  the  energy-quotient 
in  a  series  of  cases  studied  by  him.  Other  figures  could  be  quoted  varjdng 
from  those  of  Heubner.  The  fact  appears  to  be  that  the  energy-quotient 
can  be  regarded  as  no  more  than  an  average  one  and  at  the  best  a  rough 
estimate;  and  it  will  vary  greatly  with  the  individual  child,  depending 
largely  upon  its  degree  of  activity  and  its  age.  Heubner's  figures  may 
be  taken  as  a  guide  for  the  normal  child  in  the  1st  half-year;  the  number 
of  calories  required  after  this  gradually  decreasing  to  70  or  80  per  kilogram 
(30  or  36  per  pound)  by  the  end  of  the  1st  year;  but  children  under, 
weight  may  need  from  130  to  150  calories  per  kilogram  (59  to  68  per 
pound)  of  body-weight  (Morse  and  Talbot)  in  the  1st  half-year. 

Regarding  the  relationship  of  the  elements  of  the  milk  to  the  caloric 
needs,  although  certain  numbers  of  heat-units  are  produced  in  the  calo- 
rimeter by  the  combustion  of  these,  the  figures  do  not  correspond  with  the 
"utilizable"  calories  supplied  when  the  milk  is  ingested.  According  to 
the  values  given  bj^  Rubner^  1  gram  of  protein  ingested  produces  4.1 
utilizable  large  calories;  1  gram  of  fat  9.3  calories,  and  1  gram  of  carbohy- 
drate 4.1  calories.  Knowing  the  percentage  of  each  of  these  present  in 
the  milk-mixture  selected  and  the  amount  of  this  taken,  it  is  a  simple 
procedure  to  calculate  the  total  number  of  calories  received  by  the  infant 
during  the  day,  and  to  determine  whether  the  food  meets  the  energy- 
requirement.  There  is,  it  is  true,  some  difference  between  the  energy- 
production  of  the  different  sugars  respectively  and  of  starch,  but  this  is 
small  enough  to  be  disregarded.  The  further  adaptation  of  the  knowl- 
edge of  the  caloric  value  of  the  food  to  infant-feeding  will  be  considered 
in  discussing  that  subject  (p.  121). 

ORGANS  OF  RESPIRATION 

Upper  Respiratory  Passages. — The  nasal  passages  in  the  infant  are 
very  narrow,  and  the  sinuses  are  imperfectly  developed.  The  larynx 
is  situated  high  in  the  neck,  the  lower  border  of  the  cricoid  being  opposite 
the  upper  border  of  the  5th  cervical  vertebra,  instead  of  opposite  the  7th 

»  Jahrb.  f.  Kinderh.,  1910.  LXXII,  121.    Lehrb.  f.  Ivinderh.,  1911,  I,  50. 

2  Miinch.  med.  Wochenschr.,  1903,  L,  1153. 

3  Des  Kindes  Erniihning,  ete.,  1900,  I,  383. 
*  Amor.  .Jour.  Dis.  Child.,  1918,  XV,  408. 

'  Arch,  of  Pcd.,  1908,  XXV,  178. 
«  Zeitschr.  f.  Biol.,  1885,  XXI,  377. 


54  THE  DISEASES  OF  CHILDREN 

as  in  adults.  By  puberty  it  has  descended  to  the  adult  position  and 
in  boys  increases  much  in  size.  The  space  between  the  vocal  cords  of 
the  infant  is  extremely  narrow.  The  bifurcation  of  the  trachea  is  opposite 
the  3d  dorsal  vertebra  in  the  new  born,  but  opposite  the  4th  in  adults. 

Lungs. — The  lungs  of  the  infant  at  term  lie  in  a  collapsed  condition 
at  the  back  of  the  thorax.  After  air  enters  them  they  are  still  small  in 
volume  as  compared  with  adult  life,  and  continue  so  throughout  child- 
hood. They  weigh  at  birth  about  24  grams  (0.85  oz.),  the  relative  weight 
being  about  the  same  as  in  adult  life.  The  lower  level  during  infancy  is 
not  quite  as  low  in  relationship  to  the  ribs  as  it  is  in  adult  life  (Gittings, 
Fetterolf,  and  Mitchell). ^ 

Respiration. — The  type  of  respiration  in  the  infant  is  generally 
described  as  abdominal.  The  careful  experimental  studies  of  Eckerlein^ 
however,  show  that  it  is  thoracic  as  well,  neither  type  preponderating 
constantly,  but  sometimes  one  and  sometimes  the  other  being  evident. 
The  respiration  in  infancy,  and  especially  in  the  new  born,  is  very  irregu- 
lar, and  the  rate  is  much  influenced  by  the  slightest  causes.  At  times 
quite  long  pauses  take  place.  This  irregularity  is  perhaps  the  most 
striking  feature.  It  is  almost  constantly  present  when  the  child  is 
awake,  and  may  occur  even  during  sleep. 

The  average  rate  of  respiration  in  early  life  can  be  determined  only 
approximately,  and  the  estimations  of  investigators  differ  widely.  The 
following  table  of  the  rate  at  different  ages  contains  average  figures  only : 

Table  20. — Rate  of  the  Respiration  per  Minute 

New  bom 30  to  50.     Average  about  35  to  40. 

Balance  of  1st  year 25  to  35.     Average  about  30. 

1  to  2  years About  28. 

3  to  4  years About  25. 

4  to  15  years 20  to  25. 

Adult  Ufe 16  to  18. 

The  rate  of  respiration  is  from  ^^  to  3^  less  during  sleep.  Only  with  the 
beginning  of  childhood  does  the  irregularity  largely  disappear,  but  even 
then  the  rate  may  be  much  increased  by  comparatively  slight  causes. 
It  is  not  until  the  10th  year  that  the  predominating  costal  type  of  breath- 
ing develops  in  girls. 

ORGANS  OF  CIRCULATION 

Heart.  Size. — The  heart  in  the  new  born  weighs  about  24  grams  (0.85 
oz.)  according  to  the  statistics  of  H.  Vierordt^  as  compared  with  the  weight 
of  between  260  and  300  grams  (9.17  and  10.58  oz.)  in  the  adult.  It  is  thus 
proportionately  larger  in  the  infant,  equalling  0.76  per  cent,  of  the  body- 
weight  in  the  new  born,  and  0.46  per  cent,  in  the  adult.  This  disparity 
is,  however,  not  so  marked  after  the  1st  month  of  life,  from  which  time 
the  heart  grows  nearly  in  proportion  to  the  increase  in  the  body-weight, 
except  that  at  puberty  there  is  a  physiological  hypertrophy.  The  right 
ventricle  is  comparatively  large  and  strong  in  early  infancy,  its  walls  being 
almost  as  thick  as  those  of  the  left  ventricle  (v.  Starck)  ."*  From  the  2d  year 
onward,  however,  the  muscle-mass  of  the  right  ventricle  is  not  more  than 
one-half  that  of  the  left.  The  foramen  ovale — the  oval  opening  between 
the  auricles — exists  still  at  birth.     It  is  situated  at  the  lower  posterior  por- 

1  Amer.  Jour.  Dis.  CMld.,  1916,  XII,  579. 

2  Zeitsch.  f.  Geburtsh.  u.  Gynak.,  1890,  XIX,  120. 

3  Arch.  f.  Anat.  u.  Path.  Suppl.  B.,  1890,  62. 
*  Arch,  f .  Kinderh.,  1888,  IX,  247. 


ORGANS  OF  CIRCULATION  55 

tion  of  the  auricular  septum .  From  the  anterior  border  of  the  inferior  vena 
cava  arises  a  thin  membrane,  the  Eustachian  valve,  which  during  fetal 
life  diverted  the  blood  from  this  vessel  through  the  foramen  ovale  into  the 
left  auricle.  With  the  beginning  of  respiration  at  birth,  and  the  cessation 
of  circulation  in  the  umbilical  vein,  blood  ceases  to  pass  through  this 
foramen  to  any  extent,  and  it  gradually  becomes  closed  entirely  by  about 
the  10th  day  of  life,  or  often  not  for  some  months.     (See  Vol.  II,  p.  119.) 

Position. — The  position  of  the  heart  is  rather  more  horizontal  in  the 
infant,  and  regarding  its  percussion-boundaries  the  opinions  of  writers 
vary  considerably.  Von  Starck's^  review  of  these,  with  his  personal 
observations,  make  the  relative  dullness — which  is  the  most  important — 
begin  in  the  1st  year  at  the  2d  left  interspace  or,  oftener,  the  2d  rib, 
extend  to  the  right  parasternal  line,  and  reach  as  far  as  from  1  to  2  cm. 
(0.4  to  0.8  inch)  beyond  the  left  nipple-line.  The  width  at  the  position 
of  the  nipple  is  6.6  to  8  cm.  (2.6  to  3  inches).  At  the  age  of  6  years  the 
highest  extent  in  percussion-dullness  is  to  the  2d  intercostal  space. 
It  reaches  to  the  right  scarcely  as  far  as  the  parasternal  line,  and  to  the 
left  it  extends  to  the  nipple-line  or  slightly  beyond  it.  The  greatest 
average  breadth  is  10.2  cm.  (4.02  inches).  At  12  years  the  relative  dull- 
ness is  bounded  by  the  3d  rib,  the  right  edge  of  the  sternum  and  the 
left  nipple-line.  Its  greatest  breadth  is  11.5  cm.  (4.5  inches).  The  abso- 
lute dullness  in  the  1st  year  is  bounded  by  the  lower  edge  of  the  3d  rib, 
the  left. border  of  the  sternum  and  the  left  nipple-line. 

Apex. — The  apex-beat  in  the  1st  year  is  generally  found  in  or  oftener 
beyond  the  mammillary  hne,  but  quite  frequently  its  position  cannot  be 
determined.  After  this  period,  according  to  von  Starck,  although  it  may 
lie  in  various  positions  with  regard  to  the  mammillary  line,  it  is  oftenest 
outside  of  it  up  to  the  4th  year;  on  the  Hne  from  this  time  up  to  the  7th 
year,  and  within  it  after  the  9th  year.  It  is  nearly  always  in  the  4th 
interspace  in  the  1st  year,  generally  so  in  the  2d  year,  in  the  4th  and  5th 
interspaces  from  the  3d  to  the  6th  years,  and  generally  in  the  5th  inter- 
space after  the  7th  year.  The  position  of  the  apex  is,  however,  subject 
to  great  variations  within  physiological  limits.  A  distance  of  2  cm. 
(0.8  inch)  outside  the  nipple  line  is  to  be  looked  upon,  however,  with 
suspicion. 

Auscultation  shows  all  sounds  to  be  loud,  sharp  and  distinct  and  more 
widely  diffused  than  in  adults.  This  is  in  part  owing  to  the  thinness  of 
the  chest  wall.  In  infancy  and  up  to  the  age  of  4  or  5  years  the  second 
sound  is  weak  over  the  aortic  cartilage,  and  loudest  over  the  pulmonary 
cartilage,  but  is  everywhere  weaker  than  the  first  sound  of  the  heart. 
These  conditions  are  entirely  different  from  those  obtaining  in  adult  life 
(Hochsinger).^ 

Blood=vesseIs. — The  blood-vessels  in  the  child  are  relatively  of  some- 
what greater  capacity  than  in  the  adult.  The  pulmonary  artery  is  de- 
cidedly larger  than  the  ascending  aorta,  while  in  adult  life  they  are  of 
nearly  the  same  size  (Beneke.)^  The  relative  size  of  the  heart  as  compared 
with  the  diameter  of  the  ascending  aorta  is  much  less  in  children  than 
in  adults  (Beneke).  As  a  consequence  of  these  two  relations  the  general 
arterial  tension  is  less  than  in  adult  life  (see  p.  58),  and  the  blood-pressure 
in  the  lungs  in  childhood  is  greater  than  that  of  the  general  arterial  system. 

>  Loc.  cit.,  241. 

2  Die  Auscultation  des  kindlichen  Herzcns,  1890. 

'  Constitution  u.  constit.  Kranksein,  1881.  Ref.  Vierordt,  Datcn  u.  Tabellen, 
1906,  171. 


56  THE  DISEASES  OF  CHILDREN 

At  the  point  where  the  puhiionary  artery  divides  into  its  two  main 
branches  springs  in  the  fetus  the  ductus  arteriosus  BotalH.  Although 
the  largest  branch,  this  vessel  is  but  a  short  trunk  about  3^^  inch  (1.3  cm.) 
in  length  at  birth.  It  passes  obliquely  upward  and  joins  the  aorta  just 
below  the  origin  of  the  left  subclavian  artery.  Since  with  the  beginning 
of  respiration  the  blood  is  diverted  from  the  ductus  arteriosus  into  the 
lungs,  this  canal  closes  in  from  1  to  2  weeks,  persisting  only  as  a  small 
fibrous  cord  in  later  life.  Among  other  vessels  characteristic  of  ante- 
natal life,  and  still  present  at  birth,  are  the  hypogastric,  and  their  con- 
tinuation the  umbilical,  arteries.  These  are  stout  trunks  arising  from  the 
internal  iliac  arteries  and  passing  upward  beside  the  bladder  to  and 
through  the  navel,  whence,  twisted  around  the  umbilical  vein,  they  reach 
the  placenta.  The  distal  portions  of  the  arteries  within  the  body  of  the 
child  close  completely  in  from  2  to  5  days  after  birth,  forming  fibrous 
bands,  the  anterior  ligaments  of  the  bladder.  The  proximal  portions 
remain  previous  for  only  a  short  distance  from  their  origin  as  the  superior 
vesical  arteries.  The  umbilical  vein  after  entering  the  body  from  the 
navel  passes  upward  along  the  free  margin  of  the  suspensory  ligament  of 
the  liver.  After  giving  off  small  branches  to  the  hepatic  substance  it 
divides  in  the  transverse  fissure  into  two  main  branches,  of  which  the 
larger  and  shorter  joins  the  portal  vein.  The  other,  the  ductus  venosus, 
continues  along  the  posterior  longitudinal  fissure  of  the  liver  and  joins  the 
hepatic  vein  where  this  empties  into  the  ascending  cava.  Both  the 
umbilical  vein  and  the  ductus  venosus  close  completely  in  from  2  to  5 
days  after  birth,  the  part  of  the  former  within  the  body  finally  becoming 
the  round  ligament  of  the  liver. 

The  activity  of  the  circulation  is  greater  in  the  child.  K.  Vierordt^ 
estimates  that  the  time  elapsing  from  the  moment  the  blood  leaves  the 
heart  until  it  returns  to  it  is  in  the  new  born  12.1  seconds,  at  3  years 
15.0  seconds,  at  14  years  18.6  seconds  and  in  the  adult  22.1  seconds. 

The  circulation  during  fetal  life  and  the  changes  which  take  place 
at  birth  have  so  intimate  a  relation  to  congenital  diseases  of  the  heart 
that  they  will  be  described  in  connection  with  cardiac  disorders. 

Pulse. — Even  in  health  the  pulse  tends  to  be  somewhat  irregular 
in  force  and  frequency,  especially  during  infancy,  and  even  later  than  this 
a  certain  degree  of  irregularity  is  common  and  cannot  be  considered  patho- 
logical. Trifling  causes,  such  as  crying,  nursing  or  any  excitement  or 
exercise  increase  the  pulse  rate  from  20  to  40  beats  per  minute.  It  is 
often  not  easy  to  feel  the  radial  pulse  in  the  first  months.  The  rate  is  less 
when  the  child  is  lying  than  when  sitting,  and  sitting  than  when  standing, 
and  is  16  to  20  beats  less  during  sleep.  It  diminishes  also  with  increasing 
age,  but  the  figures  of  different  observers  vary  much.  An  approximation 
would  be  expressed  by  the  following: 

Table  21. — Pulse-Rate  During  Infancy  and  Childhood 

Birth 130  to  150 

1st  month 120  to  140 

1  to  6  months About  130 

6  to  8  months About  120 

1  to  2  years 110  to  120 

2  to  4  years 90  to  110 

6  to  10  years 90  to  100 

10  to  14  years 80  to    90 

The  rate  is  slightly  greater  in  females  except  in  the  first  few  months. 
'  Gerjiardt's  Handb.  d.  Ivinderkrh.,  I,  107. 


ORGANS  OF  CIRCULATION 


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58  THE  DISEASES  OF  CHILDREN 

Townsend^  has  shown  that  at  birth  sex  has  no  influence  on  the  rapidity. 
Dichrotism  is  absent  or  imperfectly  developed  in  the  pulse  of  children, 
and  does  not  appear  until  the  age  of  from  10  to  14  years  (Keating  and 
Edwards).^ 

Blood=pressure. — The  blood-pressure  is  lowest  in  children,  and 
exhibits  little  if  any  increase  until  puberty  is  approached,  when  a  more 
abrupt  increase  occurs.  Probably  the  most  extensive  and  carefully  con- 
ducted studies  are  those  by  Judson  and  Nicholson,^  and  their  results  may 
be  taken  as  the  'most  reliable.  These  are  shown  in  comparison  with  the 
investigations  of  others  in  the  table  rearranged  from  that  given  by  them. 
The  author^  found  it  impossible  to  determine  any  reliable  average  normal 
readings  for  subjects  under  3  years  of  age.  The  figures  in  the  table 
indicate  measures  recorded  in  millimeters  of  mercury. 

BLOOD 

Blood.  Amount  and  Specific  Gravity. — The  blood  in  the  new  born 
constitutes  about  ji^  of  the  body-weight  against  3^3  in  adult  life.  If 
tying  of  the  cord  is  deferred  the  percentage  is  temporarily  increased  (^^ 
of  the  body-weight  (Schiicking).^  The  specific  gravity  in  the  new  born 
is  estimated  by  Lloyd  Jones®  to  be  highest  at  birth,  equalling  1066,  but 
by  the  end  of  the  2d  week  it  has  fallen  rapidly  and  continues  to  decrease 
until  the  age  of  2  or  3  years  when  it  equals  1048  or  1050.  Then  it  gradu- 
ally increases  until  puberty. 

Hemoglobin. — The  percentage  of  hemoglobin  is  generally  conceded 
to  be  higher  in  the  new  born,  being  then  decidedly  over  100  per  cent. 
It  diminishes  rapidly  and  reaches  its  minimum  in  the  1st  month,  falling 
almost  to  50  per  cent.  This  low  percentage  continues  for  the  first  6 
months  or  1st  year,  after  which  it  rises  slowly,  keeping  pace  with  the  spe- 
cific gravity.  The  percentage  in  childhood  varies  normally  from  65' 
to  95  per  cent. 

Erythrocytes  (see  also  Vol.  II,  p.  454  and  Fig.  394) . — The  number  of  red 
blood-corpuscles  varies  greatly  according  to  different  statistics.  It  is  rela- 
tively high  in  the  new  born,  exceeding  the  proportion  in  adult  life.  Stengel 
and  White^  give  5,742,080  per  c.mm.  as  the  average  at  birth  obtained  from 
the  statistics  of  a  number  of  observers.  Biffi  and  Galh^  found  the  number 
as  high  as  7,000,000  in  one  instance.  A  decrease  in  number  begins  after  the 
2d  day  and  goes  on  rapidly,  about  500,000  being  lost  in  the  first  2  weeks 
(Schiff).^  The  diminution  continues  to  exist  during  the  1st  year,  and 
then  there  follows  a  gradual  increase  up  to  the  age  of  from  8  to  12  years 
when  the  number  normal  for  adults  is  attained  (Stengel  and  White). 
The  average  number  of  red  blood-cells  in  early  and  later  childhood  is 
4,000,000  to  4,500,000.  Nucleated  red  blood-corpuscles  (normoblasts) 
occur  in  the  fetus,  and  in  small  numbers  during  the  early  days  of  life, 
but  after  the  1st  week  their  presence  is  unusual.  The  size  of  the  red  cor- 
puscles varies  very  much  in  the  new  born,  pale  corpuscles  deprived  of 

1  Best.  Med.  and  Surg.  Jour.,  1896,  CXXXIV,  484. 

2  Arch,  of  Ped.,  1888,  Dec. 

3  Amer.  Jour.  Dis.  Child.,  1914,  VIII,  257. 

*  Personal  communication. 

«  Berl.  klin.  Wochenschr.,  1879,  XVI,  582. 

«  Journal  of  Physiol.,  1887,  VIII,  19;  1891,  XII,  299. 

^  University  of  Pennsylvania  Medical  Bulletin,  1901,  November. 

*  Journ.  de  physiol.  et  de  pathol.  generate,  1907,  IX,  721. 
9  Zeit.  f.  Heilk.,  1890,  XI,  17. 


GENITO-URINARY  SYSTEM  59 

their  hemoglobin  (shadow-corpuscles)  are  present  in  considerable  numbers 
(Silbermann)^  and  poikilocytes  may  be  seen.  The  fragility  of  the  red 
cells  appears  to  be  greater  than  in  adult  life.  The  coagulability  does 
not  differ  materially  from  that  of  the  blood  of  the  adult.  Flusser^  found 
the  average  coagulation-time  in  the  new  born  83^^  minutes. 

Leucocytes  (see  also  Vol.  II,  p.  455  and  Fig.  394). — The  leucocytes  are 
present  in  relatively  large  numbers  in  the  new  born,  equalling  16,000  to 
20,000  or  more  to  the  c.mm.  in  the  1st  days  of  life,  but  diminishing  to  12,000 
or  13,000  by  the  age  of  2  weeks  (Schiff).^  There  is  little  change  from  these 
figures  during  the  1st  year  of  life  (Gundobin),^  but  after  this  period  the  num- 
ber steadily  falls,  averaging  according  to  Karnizki^  approximately  9500  at 
from  1  to  6  years,  and  8000  at  from  6  to  15  years.  Rabinowitz,^  however, 
found  the  total  average  number  of  leucocytes  in  the  first  15  years  from 
6000  to  7000  as  in  adults.  There  may  be  a  very  considerable  variation 
within  physiological  limits.  Perlin^  gives  approximately  8000  to  13,000 
as  the  number  at  from  4  to  8  years  of  age,  and  7000  to  9000  at  16  years  of 
age.  The  proportion  among  the  different  forms  of  leucocytes  is  very 
variable  in  infancy  and  childhood.  At  birth  the  polymorphonuclear 
neutrophiles  constitute  nearly  75  per  cent.  (Carstanjen)^  but  within  48 
hours  the  lymphocytes  begin  to  increase  in  number.  Gundobin  gives  the 
proportion  of  lymphocytes  and  allied  forms  in  infancy  as  50  to  60  per 
cent,  and  that  of  polymorphonuclear  neutrophiles  as  28  to  40  per  cent., 
and  these  figures  may  be  assumed  as  approximately  correct.  In  adults 
they  are  24  to  38  per  cent,  and  62  to  70  per  cent,  respectively.  These 
proportions  alter  gradually,  and  by  the  age  of  3  years  they  approach  to, 
and  by  the  age  of  8  or  10  years  do  not  differ  materially  from  those  of  adult 
life.  The  number  of  eosinophiles  is  much  more  variable  in  the  blood  of 
infants  and  children,  and  may  be  considerably  increased  even  up  to  6  per 
cent.  (Carstanjen)  without  having  any  pathological  significance.  In  the 
first  weeks  of  life  a  few  myelocytes  may  be  found  and  even  after  this 
period  they  may  occur  in  a  large  variety  of  pathological  conditions 
(Zelenski  and  Cybulski).^  A  description  of  the  different  varieties  of  red 
and  of  white  cells  and  their  significance  will  be  given  under  Diseases  of 
the  Blood  (Vol.  II,  p.  454). 

GENITO-URINARY  SYSTEM 

Organs. — The  kidneys  are  distinctly  lobulated  and  comparatively 
large  at  birth  and  generally  extend  lower  than  the  crest  of  the  ilium 
especially  upon  the  right  side.  Their  weight  at  birth  is  estimated  by  H. 
Vierordf^"  at  about  23  grams  (0.81  oz.)  or  0.75  per  cent,  of  the  total  body- 
weight,  against  0.46  per  cent,  of  the  body-weight  in  adult  life.  A  few 
years  after  birth  the  kidneys  assume  the  position  occupied  in  later  life. 
The  renal  structure  in  the  new  born  often  exhibits  on  section  reddish 
yellow  streaks  toward  the  apices  of  the  papillae.  These  consist  of  deposits 
of  urates  in  the  tubules,  the  uric  acid  infarcts  described  by  Virchow. 

1  Jahrb.  f.  Kinderh.,  1887,  XXVI,  252. 

2  Monatsschr.  f.  I^nderh.,  Orig.,  1914,  XII,  705. 
^  Loc.  cit. 

*  Jahrb.  f.  Kinderh.,  1893,  XXXV,  191. 
s  Arch.  f.  Kinderh.,  1903,  XXXVI,  42. 
•Arch.  f.  Kinderh.,  1912,  LIX,  101. 
^  Jahrb.  f.  Kinderh.,  1903,  LVIII,  549. 
8  Jahrb.  f.  Kinderh.,  1900,  LII,  215. 
»  Jahrb.  f.  Kinderh.,  1904,  LX,  884. 
1"  Arch.  f.  Anat.  u.  Phys.;  Anat.  Abth.;  Suppl.  Band,  1890. 


60  THE  DISEASES  OF  CHILDREN 

The  bladder  in  the  infant  is  practically  an  abdominal  organ,  as  the 
small  pelvis  is  not  capable  of  containing  it.  The  prepuce  has  normally 
an  extremely  narrow  orifice  and  is  often  more  or  less  adherent  to  the  glans. 
The  cervix  of  the  uterus  is  relatively  long  and  the  body  small.  The  organ 
grows  but  little  until  puberty.  It  is  more  antiverted  than  in  adult  life. 
The  ovaries  lie  in  the  abdominal  cavity  at  birth  and  are  relatively  large 
(0.8  grams  (0.03  oz.)).  (Adult  7.5  grams  (0.25  oz.)  H.  Vierordt).^  The 
testicles  are  comparatively  small  (0.8  grams  (0.03  oz.)).  They  are  generally 
found  in  the  scrotum  at  birth.  The  mammary  glands  very  frequently 
become  somewhat  swollen  and  begin  to  secrete  a  milk-like  fluid  when  the 
infant  is  3  or  4  days  old.  This  secretion  is  most  abundant  about  the  10th  day 
of  life,  and  may  continue  for  several  weeks.  This  condition  of  the  breasts 
may  be  considered  physiological.  It  occurs  in  either  sex  equally  well, 
and  is  independent  of  the  general  state  of  health.  The  fluid,  sometimes 
called  "witch's  milk,"  chiefly  resembles  in  appearance  and  composition 
the  colostrum  secreted  by  the  mother  before  the  birth  of  the  child 
(Genser).2  Colostrum  corpuscles  are  always  present.  The  amount  se- 
creted is  generally  very  small,  unless  the  gland  has  been  repeatedly 
irritated,  as  by  pressure,  when  even  as  much  as  1  or  2  c.c.  (16  to  32 
minims)  maj^  be  obtained  at  a  time. 

Urine.  Amount.^ — Urine  is,  as  a  rule,  present  in  the  bladder  at 
birth,  but  it  is  in  small  quantity,  and  but  little  is  secreted  during  the  first 
2  or  3  days  of  life.  The  average  amount  at  the  first  passage  is  9.6  c.c. 
(0.326  fl.oz.),  according  to  the  observation  of  Martin  and  Ruge.^  The 
total  daily  quantity  secreted  in  the  first  2  days  is  inconstant,  but  averages 
much  less  than  later.  As  soon  as  the  child  begins  to  obtain  milk  from  the 
mother  the  secretion  of  urine  is  much  increased,  and  continues  throughout 
childhood  to  be  proportionately  greater  than  in  adult  life.  The  amount 
is  exceedingly  variable,  and  the  statements  of  different  investigators 
differ  widely.  It  is  influenced  by  many  causes,  among  them  the  amount 
of  liquid  ingested,  the  temperature  of  the  air,  and  the  state  of  the  diges- 
tion or  of  the  nervous  system. 

The  following  figures,  based  upon  many  estimations,  are  fairly  repre- 
sentative approximations : 

Table  23. — The  Daily  Secretion  of  Urine 

1st  and  2d  days 15-60      c.c.  (  0.5-  2.0  fl.oz.) 

3d  to  10th  day 100-300    c.c.  (  3.4-10.1  fl.oz.) 

10th  day  to  2  months 250-450    c.c.  (  8.5-15.2  fl.oz.) 

2  months  to  1  year 400-500    c.c.  (13.5-16.9  fl.oz.) 

1  to  3  years. . .' 500-600    c.c.  (16.9-20.3  fl.oz.) 

3  to  5  years 600-700    c.c.  (20.3-23.7  fl.oz.) 

5  to  8  years 650-1000  c.c.  (22.0-33.8  fl.oz.) 

8  to  14  years 800-1400  c.c.  (27.0-47.3  fl.oz.) 

The  studies  of  Churchill^  give  amounts  decidedly  less  than  these. 
Fuller  details  may  be  found  in  the  writings  of  Martin  and  Ruge,^  Cruse,^ 
Herz,^  Schiff,^  Camerer,^  Lesne  and  Merklen^"  and  others. 

1  Daten  u.  Tabellen,  1890,  29. 

2  Jahrb.  f.  Ivinderh.,  1876,  IX,  160. 

3  Zeitsch.  f.  Geburtsh.  u.  Frauenkr.,  1876,  I,  279. 
*  Arch,  of  Ped.,  1898,  XV,  fi46. 

6  Xjoc  cit 

«  Jahrb.  'f.  Kinderh.,  1877,  XI,  393. 
'  Wien.  med.  Wochenschr.,  1888,  XXXVIII,  1510. 
8  .Jahrb.  f.  Kinderh.,  1893,  XXXV,  21. 
'Wurtenb.  Correspondbl.,  1876,  XLVI,  No.  11. 
'"  Rev.  mens,  des  mal.  de  I'enf.,  1901,  61. 


GENJTO-URINARY  SYSTEM  61 

Frequency  of  Micturition. — This  varies  from  2  or  3  up  to  6  times  on 
the  1st  and  2d  days  of  hfe.  Quite  commonly  the  evacuation  does  not 
take  place  until  more  than  12  hours  from  birth,  and  not  infrequently  not 
until  on  the  2d  or  even  the  3d  day  of  life.  After  this  excretion  is  very 
frequent  during  infancy,  var3dng  anywhere  from  5  or  6  to  even  sometimes 
30  or  40  times  in  the  twenty-four  hours,  the  urine  being  often  retained 
several  hours  during  sleep.  EngeP  studied  the  frequency  of  micturition 
by  an  automatically  registering  electrical  apparatus,  and  found  it  varying 
from  10  to  30  times  in  twenty-four  hours,  with  a  normal  average  of  25. 
After  control  of  the  bladder  is  obtained  the  frequency  of  urination  varies 
from  6  to  8  times  in  twenty-four  hours. 

Physical  and  Chemical  Characteristics  of  the  Urine. — The  specific 
gravity  of  the  urine  during  the  first  few  days  of  life  is  high  as  compared 
with  that  of  later  periods  (1012,  Martin  and  Ruge).^  After  the  ingestion 
of  milk  begins  it  rapidly  falls  to  1002-1006,  but  when  a  mixed  diet  is 
commenced  it  gradually  increases,  and  when  the  child  is  5  or  6  years 
old  the  specific  gravity  is  about  the  same  as  in  the  adult. 

In  appearance  the  secretion  is  at  first  highly  colored  and  slightly 
turbid,  owing  to  the  concentration  and  to  the  presence  of  urates  and 
mucus.  Later,  even  during  childhood,  it  is  generally  of  a  paler  yellow  than 
in  adult  life.  Sometimes  in  infancy,  particularly  in  the  new  born,  it 
stains  the  diaper  a  faintly  reddish  color  through  the  deposition  of  urates. 
The  reaction,  at  first  decidedly  acid,  soon  becomes  usually  neutral. 
Odor  is  almost  absent  in  infancy  and  even  in  childhood,  unless  the  urine  is 
high-colored.  The  ammoniacal  odor  often  noted  in  the  nursery  usually 
is  due  to  lack  of  care  in  changing  the  diapers,  the  urine  decomposing 
after  it  has  been  passed.     This  is  especially  true  if  indigestion  is  present. 

As  regards  the  chemical  constituents  there  is  very  little  or  no  urea  in 
the  urine  at  birth.  The  proportion  is  much  increased  by  the  3d  day,  but 
is  still  relatively  low  during  infancy.  Phosphates,  chlorides  and  sulphates 
are  also  present  in  relatively  small  amounts.  The  proportions  of  all  of 
these  are  increased  when  a  mixed  diet  is  commenced,  but  are  still  less 
than  in  adults.  The  amount  of  urea,  however,  as  compared  with  the 
body  weight  is  greater  in  childhood  than  in  adult  life.  The  percentage 
of  uric  acid  is  especially  large  in  the  new  born,  and,  though  then  diminish- 
ing, still  remains  throughout  childhood  in  excess  of  that  of  adult  Hfe. 
The  relation  of  uric  acid  to  urea  is  1  :  14  in  the  new  born,  and  but  about 
1  :  70  in  the  adult. 

The  urine  of  healthy  breast-fed  infants  usually  contains  no  indican, 
but  in  those  fed  artificially  it  is  generallj^  present  in  small  quantity. 
Older  children  on  mixed  diet  exhibit  indican  to  the  same  extent  as  do 
adults. 

Albumin  in  small  amount  may  very  often  be  found  in  the  urine  of 
healthy  new-born  infants.  Traces  of  sugar  may  sometimes  occur  in 
healthy  infants,  according  to  the  statements  of  a  numl)er  of  investigators. 
Reuss''  found  glycocol  a  normal  constituent  in  the  new  born,  and 
Ostrowski^  observed  urobilinuria  frequently  in  hoaltliy  infants.  Rennin 
and  pepsin  are  said  by  Pechstcin''  to  b(>  always  discoverable  in  the  urine 
of  children.     Small  amounts  of  the  acetone-bodies  are  normally  present 

1  Deut.  nied.  Wochenschr.,  1914,  XL,  1960. 

^  Loc.  cit. 

'  Zeit.  f.  Kinderh.,  Orig.,  1911-12,  III,  12;  286. 

*  Przeglad  lekarski,  1912,  No.  10.    Ref.  Monafssclir.  f.  Kiiidorh.,  Rof.,  191.3,  XII,  172. 

6  Zeit.  f.  Kinderh.,  Urig.,  1911,  I,  357. 


62  THE  DISEASES  OF  CHILDREN 

(Veeder  and  Johnston);^  and  phenol  is  constantly  found  (Moore). ^ 
Microscopically  nothing  characteristic  is  noticed  except  that  the  presence 
of  hyaline  casts  is  not  unusual  in  the  case  of  young  infants. 

THYMUS  GLAND 

The  thymus  gland  is  essentially  an  organ  of  early  life.  Its  size  is 
subject  to  great  variation.  According  to  Friedleben,^  whose  figures  have 
been  much  quoted,  the  length  from  birth  to  the  9th  month  averages 
approximately  6.9  cm.  (2.71  inches) ;  from  9  months  to  puberty  8.4  cm. 
(3.30  inches),  and  in  adult  life  from  10  to  13  cm.  (3.94  to  5.12  inches), 
the  glandular  tissue  being  then  largely  replaced  by  fat.  At  birth  the 
gland  fills  up  much  of  the  space  in  the  lower  anterior  portion  of  the  neck 
and  behind  the  upper  part  of  the  sternum.  Its  weight,  according  to  his 
figures,*  are: 

Table  24 

Birth 14 . 3  grams  (0 .  51  oz.) 

1-9  months 20 . 7  grams  (0 .  73  oz.) 

9-24  months 27 . 3  grams  (0 .  96  oz.) 

2-14  years 27 . 0  grams  (0 .  95  oz.) 

15-25  years 22. 1  grams  (0.78  oz.) 

25-35  years 3.1  grams  (0.11  oz.) 

Some  more  recent  investigations  gave  reason  to  believe,  however, 
that  these  estimations  are  too  high.  The  careful  studies  of  Bovaird  and 
Nicoll,^  based  upon  the  examination  of  495  glands,  furnish  figures  for 
weight  decidedly  less.  The  birth-weight  was  found  to  average  7.7  grams 
(0.27  oz.),  with  a  decrease  to  5.9  grams  (0.21  oz.)  for  the  first  5  years  of 
life,  and  a  still  further  dimunition  after  this  period.  Dudgeon^ 
found  the  normal  weight  in  infants  up  to  2  years  of  age  to  be  from 
7  to  10  grams  (0.25  to  0.35  oz.).  Vierordt,'^  from  his  comparison 
of  different  statistics,  placed  the  average  birth-weight  as  8.15  grams 
(0.29  oz.).  On  the  other  hand,  Hammar,^  in  a  study  upon  the 
thymus  glands  of  126  well-nourished  individuals  dying  suddenly  or 
after  very  acute  illness,  and  consequently  with  presumably  normal  glands, 
found  that  the  weight  at  birth  averaged  13.26  grams  (0.47  oz.) ;  from  1  to 
5  years  22.98  grams  (0.81  oz.) ;  from  6  to  10  years  26.10  grams  (0.92  oz.), 
and  from  11  to  15  years  37.52  grams  (1.32  oz.).  It  is  evident  that  a 
decided  difference  of  opinion  still  exists  which  has  yet  to  be  settled;  but 
it  would  seem  safe  to  assume  that  any  gland  weighing  more  than  10  to  15 
grams  (0.35  to  0.53  oz.)  is  above  the  average  weight,  although  the  possible 
range  in  normal  weights  is  to  be  borne  in  mind  (from  5  to  20  grams) 
(0.18  to  0.70  oz.)  (Schridde).^  The  gland  is  loosely  attached  to  the 
sternum,  but  firmly  to  the  pericardium.  Its  position  may  be  recognized 
by  radiography  as  well  as  by  percussion.  (See  Diseases  of  the  Thymus 
Gland,  Vol.  II,  p.  517.) 

1  Amer.  Jour.  Dis.  Child.,  1916,  XI,  291. 

2  Amer.  Jour.  Dis.  Child.,  1917,  XIII,  15. 
2  Die  Physiologie  der  Thymusdrl'ise,  1858. 

*  As  Friedleben's  figures  are  given  in  the  old  grains  of  Cologne,  I  have  used  the 
equivalents  as  quoted  by  Friedjung  (Pfaundler  und  Schlossmann,  Handb.  der  Kinderh., 
1906,  II,  1,  394). 

^  Arch,  of  Ped.,  1906,  XXIII,  641. 

«  Path.  Soc.  Transac,  London,  1904,  LV,  151. 

'  Daten  und  Tabellen,  1906^  44. 

8  Ergebn.  d.  Anat.  u.  Entwickelungesch.,  1909,  XIX,  253. 

s  Munch,  med.  Woch.,  1914,  LXI,  2161. 


TEMPERATURE  63 

SUPRARENAL  BODIES 

The  suprarenal  bodies  are  relatively  very  large  in  infancy,  weighing 
about  as  much  as  in  adult  life. 

SPLEEN 

The  spleen  weighs  approximately  10  grams  (0.35  oz.)  at  birth 
(Vierordt).^  Its  relative  weight  is  slightly  greater  at  this  period  than 
in  adult  life.     (Adult  163  grams  (5.75  oz.)  Vierordt.) 

THYROID  GLAND 

The  thyroid  gland  is  comparatively  large  in  infancy,  weighing, 
according  to  the  statistics  of  Vierordt,^  4.85  to  9.75  grams  (0.17  to  0.34 
o?.).  This  makes  its  size  as  compared  with  the  body-weight  3  times  as 
great  as  in  adult  life.  The  isthmus  is  small  in  children,  but  can  be  dis- 
covered by  palpation,  if  the  subcutaneous  fatty  tissue  of  the  neck  is  not 
too  abundant  at  the  point  where  it  crosses  the  trachea  below  the  cricoid 
cartilage.  The  lateral  lobes,  however,  cannot  be  felt,  and  even  a  some- 
what enlarged  gland  may  be  impossible  of  recognition  during  life. 

TEMPERATURE 

The  temperature  of  the  body  at  birth,  taken  in  the  rectum,  averages 
in  the  neighborhood  of  37.8°C.  (100.4°F.)  ( Vierordt). ^  Within  an  hour 
or  two  it  falls  temporarily  about  1.7°C.  (3.1°F.)  and  then,  before  or  by 
the  end  of  the  1st  day  of  life,  rises  again  to  37.6°C.  (99.7°F.)  (37.59°C. 
Forster).*  Throughout  infancy  a  daily  rise  in  temperature  begins  at  2  or 
3  A.M.,  which  gradually  increases  and  reaches  its  maximum  in  the  early 
afternoon,  to  be  followed  by  a  fall  which  commences  toward  evening  and 
continues  until  after  midnight.  The  very  extensive  investigations  of 
Jundell,^  upon  over  3000  records,  show  that  the  daily  fluctuation  in  the 
second  half  of  the  1st  week  in  perfectly  healthy  infants  does  not  amount 
to  more  than  0.1°C.  (0.18°F.),  by  the  age  of  1  month  averages  about 
0.25°C.  (0.45°F.),  and  by  6  months  reaches  a  range  of  0.5°C.  (0.9°F.). 
In  early  childhood  the  daily  fluctuation  amounts  to  nearly  1°C.  (1.8°F.), 
which  is  somewhat  greater  than  in  adult  life.  The  average  temperature 
of  childhood  is  rather  higher  than  in  adults  (0.3°C.  Vierordt)  (0.54°F.), 
and  elevations  are  more  readily  produced  by  slighter  causes.  After  the 
ingestion  of  nourishment  infants  show  a  slight  fall  of  temperature,  fol- 
lowed soon  by  a  slight  temporary  rise  above  that  existing  before  nurs- 
ing (Demme).^  The  temperature  during  sleep  is  slightly  lower  than 
when  the  infant  is  awake,  and  somewhat  higher  after  exercise  or  crying. 
External  influences,  too,  affect  it.  Thus  variations  in  the  temperature  of 
the  surroundings  may  elevate  or  depress  that  of  the  infant.  It  is  to  be 
noted  also  that  the  axillary  temperature  in  normal  children  is  from 
0.3  to  0.9°C.  (0.54°  to  1.6°F.')  less  than  the  rectal  (Demme),  and  in  sick 
children  from  0.5  to  l.^C.  (0.9  to  2°F.). 

1  Daten  u.  Tabellen,  1906,  29. 

2  Daten  u.  Tabellen,  190G,  42. 

3  Daten  u.  Tabellen,  190(5,  360. 

*  Journ.  f.  Kinderkrh.,  1862,  XXXIX,  1. 
'  Jahrb.  f.  Kinderh.,  1904,  LIX,  521. 

*  14.  med.  Bericht.  d.  Jennersch.  Kindersp.  in  Bern,  1S77,  7  .Ref.  Vierordt,  loc.  cit., 
364. 


64  THE  DISEASES  OF  CHILDREN 

NERVOUS  SYSTEM 

Brain. — The  brain  of  the  new  born  is  proportionately  very  heavy, 
eqiialUng  about  380  grams  (13.4:  oz.)  or  from  12  to  13  per  cent,  of  the  body- 
weight,  while  in  adults  it  is  only  about  2  per  cent.  Growth  is  rapid, 
especially  in  the  1st  year,  the  weight  increasing  nearly  23^-^  times.  After 
about  the  5th  year,  however,  the  rate  of  increase  in  weight  is  very  slow. 

The  following  table,  after  Vierordt,^  shows  the  weight  at  different 
ages: 

Table  25. — -Weight  of  the  Brain  at  Different  Ages 


Male  Female 


Birth 

6  months . 

1  year. . . . 

2  years . . . 
5  years . . . 
10  years. . 
25  5'ears. . 


381  grams  (13.4  oz.)  384  grams  (13.5  oz.) 

632  grams  (22.3  oz.)  575  grams  (20.3  oz.) 

945  grams  (33.3  oz.)  872  grams  (30.8  oz.) 

1025  grams  (36.2  oz.)  961  grams  (34.0  oz.) 

1263  grams  (44.6  oz.)  1221  grams  (43.1  oz.) 

1408  grams  (49.7  oz.)  1284  grams  (45.3  oz.) 

1431  grams  (50.5  oz.)  1224  grams  (43.2  oz.) 


The  cerebellum  is  relatively  smaller  than  the  cerebrum  as  compared 
with  adult  life.  The  brain-substance  is  very  soft  at  birth,  and  the  grey 
matter  is  not  sharply  differentiated  from  the  white.  Although  the  convo- 
lutions are  less  evident  than  in  adult  life  they  all  become  visible  by  the 
age  of  5  weeks.  The  dura  mater  is  adherent  during  the  1st  and  often 
also  during  the  2d  year.  There  is  a  greater  amount  of  fluid  in  the  subdural 
space  than  later  in  life. 

Spinal  Cord. — The  spinal  cord  at  birth  is  comparatively  heavy, 
weighing  5.5  grams  (0.19  oz.)  or  0.18  per  cent,  of  the  body- weight 
(Vierordt)  against  0.0(5  per  cent,  in  adults.  At  birth  it  extends  downward 
sometimes  to  the  3d  lumbar  vertebra,  but  in  other  cases  only  to  the  1st, 
as  in  adults. 

DEVELOPMENT  OF  MUSCULAR  AND  NERVOUS  FUNCTIONS 

For  the  first  few  weeks  of  Ufe  the  infant  lies  very  still  wherever  placed, 
unable  to  change  its  position,  and  sleeping  most  of  the  twenty-four  hours. 
The  action  of  the  flexor  muscles  preponderates  to  some  extent,  and  the 
hands  are  usually  clinched  much  of  the  time,  the  head  sunken  forward, 
the  back  convex,  and  the  forearms,  thighs  and  legs  flexed  and  drawn  to  the 
body.  The  head  cannot  be  held  erect,  the  alterations  in  the  expression 
of  the  face  are  meaningless,  and  the  apparent  smile  sometimes  seen  is  not 
expressive  of  comfort.  Any  movements  which  occur  are  automatic  or 
reflex.  Sucking  at  the  nipple,  for  instance,  and  the  grasping  by  the  hand 
of  an  object  placed  in  it  are  done  purely  unconsciously.  This  automatic 
grasp  of  the  new  born  is  very  powerful;  so  much  so  that  the  child  can  some- 
times be  raised  entirely  from  the  bed  before  it  relaxes.  Soon  a  very  dis- 
tinct increase  in  general  power  takes  place.  The  motions  of  the  legs  and 
arms  become  very  active,  but  uncontrolled  and  still  purposeless.  In 
the  2d  month  the  head  can  be  held  upright  to  some  extent,  and  by  the 
3d  or  4th  month  very  well.  By  the  age  of  3  months,  or  sometimes 
a  little  sooner,  purposeful  efforts  at  grasping  objects  begin,  but  without 
any  idea  whatever  of  distance  being  shown.  By  6  months,  although  the 
1  Arch.  f.  Anat.  u.  Phys.;  Anat.  Abth.;  Suppl.  Band,  1890,  62. 


DEVELOPMENT  OF  SPECIAL  SENSES  AND  MENTAL  POWERS     65 

motions  are  still  largely  impulsive,  the  child  can  make  many  well-directed 
movements  and  can  grasp  for  and  play  with  its  toys.  At  this  age  it  can 
sit  supported  very  well,  and  unsupported  to  some  extent,  although  fre- 
quently falling  backward  until  the  age  of  9  or  10  months.  The  age  when 
the  infant  is  able  to  roll  over  varies  greatly.  A  few  can  accomplish  this 
by  3  months,  but  the  majority  not  until  much  later. 

At  about  the  age  of  6  months  the  infant  will  often  try  to  stand  if  held 
on  its  feet  in  the  lap.  At  7  or  8  months  it  makes  attempts  at  creeping 
or  at  moving  along  the  floor  or  bed  in  some  other  manner.  Some  children, 
however,  never  creep.  When  a  year  old,  or  sometimes  even  when  9  or  10 
months,  it  will  stand,  holding  to  objects.  Walking,  while  supporting 
itself  by  the  wall  or  by  furniture  begins  soon  after  1  year  of  age,  the  time 
varying  greatly,  and  the  power  to  walk  without  support  is  gained  in  a  few 
months  more.  Falls  are,  of  course,  very  frequent,  and  these  are  nearly 
always  backward,  bringing  the  child  into  a  sitting  position.  This  is  due 
to  the  comparative  weakness  of  the  extensor  muscles.  The  toes  are 
always  turned  in  when  walking,  and  this  condition  is  overcome  only 
very  gradually. 

The  time  for  the  acquisition  of  muscular  and  nervous  control  of  the 
passage  of  urine  depends  largely  upon  training.  With  care  it  is  sometimes 
possible  to  teach  an  infant  of  even  3  or  4  months,  at  least  during  the  day. 
Usually,  however,  the  control  by  day  is  not  acquired  until  sometime  in 
the  2d  year.  The  age  of  2  years  is  an  extreme  limit  for  children  with 
whom  any  effort  at  instruction  has  been  made.  The  same  statements 
apply  to  the  control  of  the  fecal  evacuations. 

Reflex  Action. — This  is,  for  the  most  part,  well-developed  in  the  new 
born.  Many  of  its  forms  are  entirely  uncontrolled  by  the  inhibitory 
influence  which  develops  later;  as,  for  instance,  reflex  evacuation  of  the 
bowels  and  the  bladder.  Some  of  the  reflex  "movements  which  persist 
throughout  life,  as  the  plantar  and  the  patellar  reflexes,  are,  on  the  whole, 
not  so  uniformly  well  shown  in  the  1st  and  2d  years  as  later.  Others, 
such  as  the  abdominal,  cremasteric,  corneal  and  pupillary  reflexes,  are 
fully  developed  from  birth.  The  investigations  of  Engstler^  and  of  Levi^ 
showed  that  the  plantar  reflex  in  the  new  born  is  characterized  by  dorsal 
flexion  of  the  toes  (Babinski  reflex).  Gradually  this  condition  changes, 
but  it  is  not  until  the  3d  year  that  plantar  flexion  is  the  rule. 

DEVELOPMENT  OF  SPECIAL  SENSES  AND  MENTAL  POWERS 

Sight. — In  the  first  weeks  the  child  probably  cannot  see,  except  to 
distinguish  light  from  darkness,  and  will  not  wink  when  the  finger  is 
brought  near  the  eye.  The  perception  of  light  is  decided,  and  sometimes 
evidently  unpleasant,  since  the  infant  closes  its  lids  whenever  the  light 
is  too  bi'ight.  The  eyes  are  expressionless  and  move  slowly,  and  more  or 
less  of  lack  of  coordination  persists  until  the  age  of  3  months.  The  pujiils 
react  promptly  to  light  at  once  after  birth.  Between  the  ages  of  3  and  0 
weeks  the  baby  can  fix  its  eyes  upon  objects,  but  even  by  the  Gtli  day 
it  may  turn  its  face  to  the  light.  By  7  weeks  the  reflex  closing  of  the  lids 
on  the  approach  of  an  object  close  to  the  eyes  is  well  developed.  Colors 
probably  cannot  be  distinguished  until  the  age  of  a  year  and  the  ability 
increases  verj^  slowly  with  many  children.     Yellow,  white  and  red  appear 

'  Wicn.  klin.  Woclicnscli.,  lOO.'i,  XVIIl,  507. 
^Ciaz.  dfs  nuilad.  infant.,  IDO.'J,  V,  277. 


66  THE  DISEASES  OF  CHILDREN 

to  be  recognized  before  green  and  blue.  In  later  childhood  the  power  of 
sight  is  unusually  strong,  and  light  can  be  endured  better  than  in  adult 
life.     Hyperopia  seems  to  be  the  normal  condition  in  the  new  born. 

Hearing. — This  is  absent  on  the  day  of  birth,  due  probably  in  part 
to  the  filling  of  the  tympanic  cavity  by  mucus  and  swollen  mucous 
membrane,  in  part  to  the  approximation  of  the  walls  of  the  meatus.  In 
a  few  days,  however,  air  begins  to  enter  the  cavity  and  infants  can  then 
be  awakened  by  loud  noises.  In  the  early  months  the  sense  of  hearing 
is  very  acute  and  sleeping  children  are  very  easily  awakened  by  noise, 
and  they  are  especially  sensitive  to  high  and  shrill  tones.  Infants  of  3 
months  can  generally  recognize  the  direction  from  which  sound  comes 
and  ma}^  turn  the  head  toward  it. 

Musical  tones  are  sometimes  recognized  between  the  ages  of  1  and  2 
years,  and  a  child  of  2  years  may  distinctly  prefer  one  tune  to  another 
and  may  even  know  it  by  name.  Very  often,  however,  the  ability  to 
recognize  tunes  does  not  come  until  later  in  childhood,  and  sometimes 
never. 

In  later  childhood  the  hearing  is  particularly  acute,  and  very  weak 
or  very  high  tones  are  detected  which  an  adult  cannot  hear  at  all. 

Smell. — The  sense  of  smell  probably  exists  in  the  new  born,  but  is 
certainly  sHght,  although  infants  born  blind  are  said  to  be  able  to  recog- 
nize the  odor  of  milk.  Except  for  the  ability  to  differentiate  pleasant 
from  distinctly  unpleasant  odors,  the  sense  of  smell  develops,  on  the  whole, 
slowly,  and  is  not  fully  present  until  later  childhood. 

Taste. — This  is  present  at  birth  and  the  new  born  can  distinguish 
pleasant  and  unpleasant  substances,  such  as  sweet  and  bitter.  Although 
the  sense  of  taste  during  infancy  does  not  always  appear  very  keen, 
many  infants  taking  without  objection  medicine  which  is  generally  con- 
sidered decidedly  unpleasant,  this  probably  depends,  as  Preyer^  has 
pointed  out,  on  the  fact  that  the  taste  for  sweet  is  so  remarkably  developed  • 
that  the  infant  often  willingly  takes  anything  to  which  sugar  has  been 
added  in  considerable  quantity. 

Touch. — This  is  present  at  birth,  and  the  touching  of  the  eyelashes, 
the  lips  or  the  hands  promptly  causes  reflex  movements.  It  is,  however, 
much  less  strongly  developed  than  later.  Preyer  found  the  forehead  and 
the  external  auditory  meatus  especially  sensitive.  In  older  children  the 
tactile  sensibility  is  very  acute.  The  sensibility  to  pain  is  quite  distinct 
in  young  infants,  but  comparatively  poorly  developed  if  the  area  affected 
is  small.  Thus  the  pricking  of  the  finger  or  toe  during  a  })lood-examina- 
tion,  or  the  scratching  of  the  skin  in  vaccination  frequently  produces  no 
crying. 

The  temperature  sense  in  general,  though  not  well  developed,  is  still 
probably  present  in  the  new  born  as  is  shown  by  the  comfort  a  warm 
bath  gives,  and  the  crying  produced  by  chilling  of  the  surface.  In  the 
mouth  the  temperature-sense  is  active  from  birth,  as  evidenced  by  the 
refusal  of  many  infants  to  take  cold  milk,  while  warm  is  readily  accepted. 

Mental  Powers. — The  infant  at  birth  is  largely  in  a  vegetative 
state,  and  its  mental  powers  are  dormant.  On  the  whole  its  sensations 
are  probably  pleasurable,  or  at  least  not  disagreeable,  and  those  which 
are  not  are  evidenced  by  a  cry.  Hunger,  pain,  cold,  lack  of  sleep  and  the 
like  are  expressed  in  this  manner  without  the  infant  being  actually  con- 
scious that  anything  ails  it.     In  the  2d  month  it  expresses  pleasure 

'  Die  Seele  des  Kindes,  90. 


DEVELOPMENT  OF  SPECIAL  SENSES  AND  MENTAL  POWERS     67 

by  smiling,  as  when  tickled;  but  smiles  before  this  age  are  merely  reflex, 
and  often  indicative  of  pain.  It  is  not  until  the  age  of  5  or  6  months  that 
the  average  baby  really  laughs.  In  the  3d  month  there  is  distinct 
evidence  of  mind  and  thought.  At  this  age  the  first  signs  of  memory 
are  witnessed,  the  child  clearly  recognizing  its  mother  by  smiling  at  her 
approach,  or  by  ceasing  to  cry  from  hunger  when  preparations  for  nurs- 
ing are  witnessed.  In  the  3d  or  4th  month  certain  tones  awaken  its 
attention  and  it  is  interested  in  bright  and  especially  in  moving  objects. 
It  also  shows  its  mental  activity  by  grasping  after  objects,  and  by  at- 
tempting, if  it  reaches  them,  to  put  them  into  its  mouth.  Before  the 
age  of  6  months  the  infant  indicates  its  recognition  of  other  persons 
than  the  mother  by  smiling  at  them  and  realizes  the  difference  between 
strange  and  familiar  places.  When  9  months  old  it  will  stretch  out  both 
hands  intelligently,  or  will  give  its  hand  when  told  to  do  so,  and  enjoys 
a  game  of  "peep-bo."  It  clearly  understands  many  things  spoken  to  it, 
even  before  it  is  able  to  speak  any  words  itself.  By  the  completion  of  the 
1st  year  it  has  learned  distinctly  to  indicate  by  expression  of  face  and  by 
gestures  its  likes  and  dislikes  for  the  persons  and  acts  of  others. 

In  the  2d  year  the  baby  has  some  idea  of  numbers.  Sensations  of 
joy,  anger,  fear  and  the  like  are  well  shown,  but  none  of  these  make  more 
than  a  most  transient  impression,  and  the  child  quickly  passes  from  one 
to  the  other.  In  fact,  memory  in  infancy  and  early  childhood  is  but  weak. 
Later  in  childhood,  however,  it  is  at  its  highest  point. 

Speech. — All  early  sounds  made  by  the  child  are  impulsive.  In  the 
2d  month  the  child  often  begins  to  use  certain  tones  of  voice,  frequently 
of  a  "cooing"  character,  to  express  comfort,  but  these  are  still  automatic 
in  nature.  About  the  age  of  3  or  4  months  the  infant  commences  to 
utter  a  few  different  vowel-sounds  preceded  by  certain  consonants, 
especially  m,  and  b;  then  d,  p,  n,  and  j.  These  sounds  are  still  not  in 
any  way  imitative  or  even  selected;  but  by  the  age  of  8  or  10  months 
several  such  syllables  are  pronounced  with  some  evidence  of  intent,  and 
by  the  end  of  the  1st  year  "mamma,"  "papa,"  and  even  some  other  words 
may  be  spoken  intelligently.  At  18  months  the  infant  can  express  by 
gestures  and  a  few  words  many  of  its  desires,  and  by  2  years  it  employs  very 
short  incomplete  sentences  of  two  or  three  words,  using  nouns  and  verbs. 
Qualifying  words  of  speech  are  learned  later.  The  time  at  which  speech 
is  first  acquired  is,  however,  open  to  great  variation  within  entirely  normal 
limits. 


CHAPTER  II 
HYGIENE 

Prenatal  Hygiene.^ — ^The  health  and  manner  of  Hfe  of  the  prospective 
mother  exercise  enormous  influence  upon  the  well-being  of  the  future 
child.  Constitutional  diseases,  such  as  syphilis,  affecting  her  and  all 
acute  or  chronic  maladies  require  treatment.  The  general  hygiene  must 
be  overseen,  and  especially  must  the  amount  and  nature  of  amusements 
and  of  exercise  taken  be  carefully  supervised.  Thus  the  diet  must  be 
generous  and  digestible;  the  dress  one  which  does  not  constrict;  the  con- 
dition of  the  breasts  and  nipples  carefully  attended  to  before  the  birth 
of  the  child;  violent  or  sudden  movements  avoided;  sufficient  outdoor 
life  obtained;  the  nervous  system  maintained  in  a  quiet  state,  and,  in 
general,  the  hygienic  instructions  followed  which  are  better  detailed  in 
works  upon  obstetrics. 

First  Care  of  the  New  Born. — In  from  5  to  10  minutes  after  birth, 
as  soon  as  pulsation  has  ceased  in  the  cord,  a  ligature  of  sterilized  sur- 
geon's silk  is  applied  about  13-^  inches  (3.8  cm.)  from  the  abdomen,  and 
the  cord  then  cut.  (For  further  dressing  of  the  cord,  see  p.  72.)  The  child 
is  then  wrapped  in  a  soft  and  warmed  blanket  and  laid  in  some  warm  and 
safe  place  for  a  short  time  until  its  toilet  can  be  commenced.  When  ready 
for  this  the  monthly  nurse  seats  herself  on  a  low  chair  beside  the  baby's 
bath-tub,  taking  the  child,  still  in  its  blanket,  into  her  lap,  and  having 
the  vessels  of  hot  and  cold  water,  the  bath-thermometer,  and  other  required 
articles  close  at  hand.  All  draughts  should  be  cut  off  by  the  use  of  a  screen 
and  by  closing  doors  and  windows,  and  the  bathing  done  before  an  open 
fire  or  other  source  of  heat,  unless  the  weather  is  very  warm.  The  eyes 
also  should  be  protected  against  bright  hghts.  The  surface  of  the  body 
is  now  rubbed  with  white  petrolatum  or  olive  oil  to  soften  the  vernix 
caseosa,  particular  attention  being  given  to  all  the  creases  and  folds  in  the 
skin.  Next  the  eyes  are  washed  with  a  saturated  solution  of  boric  acid 
squeezed  into  them  from  absorbent  cotton  after  separating  the  lids.  Should 
the  mother  have  had  a  suspicious  vaginal  discharge,  a  few  drops  of  a  1  per 
cent,  solution  of  nitrate  of  silver  should  be  instilled  with  a  dropper  and 
this  washed  out  later  by  normal  salt  solution ;  and  it  is  safer  to  use  this  or 
to  instill  a  stronger  solution  of  argyrol  in  every  case.  The  mouth  is  now 
washed  very  gently  with  absorbent  cotton  wrapped  around  the  nurse's 
finger  and  moistened  with  warm  sterilized  water,  and  the  nose  gently 
cleansed,  as  far  as  possible,  with  moistened  cotton.  The  face  is  washed 
with  warm  water  applied  with  a  sponge  or  wash-cloth,  but  without  soap, 
and  is  then  dried  with  a  soft  towel.  The  scalp  is  next  soaped,  washed 
and  dried.  The  toilet  of  the  head  being  now  completed,  the  rest  of  the 
body  is  rubbed  with  soap  and  water,  and  the  baby  then  placed  in  the  tub 
filled  with  water  at  100°F.  (37.8°C.),  kept  there  for  a  minute  or  two,  and 
finally  removed  to  the  nurse's  lap,  where  it  is  wrapped  in  a  fresh  flannel 
blanket,  or  in  the  flannel  apron  which  it  is  advisable  she  should  wear. 
Here  it  is  patted  thoroughly  dry  with  soft  towels,  particular  attention 
being  given  to  all  the  folds  and  creases  of  the  body,  these  parts  being 
finally  powdered  slightly  with  an  unscented  talcum  powder.     The  child  is 

68 


HYGIENE  69 

then  dressed  and  placed  in  its  bed.  Should  it  seem  chilled,  as  shown  by 
blueness  and  coldness  of  the  extremities  and  nose,  it  should  have  hot 
bottles  put  about  it,  using  great  caution  against  burning  it.  During  the 
toilet  it  is  important  to  keep  the  temperature  of  the  bath  uniform  by 
adding  hot  water  as  required. 

In  the  case  of  premature  or  weakly  children  it  is  best  to  omit  bathing 
entirely  until  the  vitality  has  become  greater,  and  to  substitute  rubbing 
every  two  or  three  days  with  warm  oil  or  petrolatum.     (See  p.  256.) 

Certain  matters  appertaining  to  the  child's  toilet  must  be  considered 
more  in  detail: 

Bathing. — Succeeding  baths  resemble  the  first,  except  that  the 
oiling  is  omitted.  In  place  of  the  tub-bath,  however,  only  a  daily 
sponging  is  given  until  the  cord  has  separated  in  order  that  the  drjmess 
of  its  dressing  shall  not  be  disturbed.  Throughout  infancy  and  child- 
hood the  bath  is  given  daily,  either  as  soon  as  the  child  wakens  in  the 
morning  or  before  the  morning  nap,  but  never  soon  after  eating.  The 
duration  of  immersion  varies  from  1  or  2  to  5  minutes,  enough  water  being 
used  to  cover  to  the  neck  when  the  baby  is  in  a  semi-reclining  position. 
The  nurse,  sitting  on  the  right  side  of  the  infant,  holds  it  in  the  tub 
by  grasping  its  left  shoulder  and  arm  with  her  left  hand,  thus  supporting 
its  head  and  back  on  her  left  forearm.  In  some  cases  the  reaction  after 
the  bath  is  unsatisfactory.     It  is  then  better  to  employ  sponging  only. 

The  temperature  of  100°F.  (37.8°C.)  of  the  first  full  bath  may  be 
diminished  gradual^,  until,  when  the  age  of  6  months  or  a  vear  has 
been  attained,  it  is  from  90°  to  95°F.  (32.2°  to  35°C.)  in  winter,  or  85° 
to  90°F.  (29.4°  to  32.2°C.)  in  hot  summer  weather,  the  reaction  of  the 
child  always  being  the  guide.  In  the  2d  year  the  temperature  may  be 
from  85°  to  90°F.  (29.4°  to  32.2°C.),  according  to  the  effect  on  the  child. 
After  the  4th  year  the  morning  bath  may  be  from  75°  to  80°F.  (23.9° 
to  26.7°C.)  given  as  a  sponge,  shower,  or  tub-bath,  with  the  duration 
brief,  the  room  warm,  and  the  drying  vigorous.  In  this  way  it  is  generally 
a  useful  tonic.  The  temperature  of  the  water  should  always  be  deter- 
mined by  a  bath-thermometer;  not  guessed  at,  as  is  too  often  the  case. 

The  hath-tub  is  commonly  of  painted  metal,  oval  in  shape.  For  the 
sake  of  greater  convenience  to  the  nurse  or  mother  it  may  be  placed  upon 
a  low  stand  when  the  bath  is  given,  or  supported  upon  cleated  slats  laid 
across  the  stationary  bath-tub  of  the  house.  A  very  convenient  tub  is  a 
folding  one  of  rubber. 

As  both  hot  and  cold  water,  or  fresh  supplies  of  water,  arc  often  needed 
a  double  sponge  basin  with  a  partition  separating  the  two  portions  is  a 
very  useful  article  for  the  baby's  toilet. 

The  baby's  basket  is  employed  to  contain  many  of  the  articles  com- 
monly used  in  the  toilet.  It  holds  soap,  hair-brushes,  sponges,  powder, 
and  the  like,  and  a  certain  amount  of  clothing.  A  wash-cloth  is  best 
suited  for  apphang  soap.  It  should  be  very  soft,  of  flannel,  diaper  cloth, 
or  cotton  stockinet.  All  folds  and  hollows  of  the  surface  should  be 
thoroughly  washed,  l)ut  no  effort  made  to  cleanse  the  auditory  canal. 

For  the  removal  of  the  soap  a  sponge  is  to  be  preferrcnl,  ;is  water  can  be 
more  easily  squeezed  from  it  upon  the  body.  It  should  ])e  of  fine  texture 
and  free  from  all  silicious  particles.  The  sponge  and  wash-cloth  maybe 
kept  in  the  pockets  of  the  baby's  basket,  but  only  after  they  have  been 
thoroughly  dried. 

The  soap  employed  should  be  unirritating,  and  free  from  exc(>ss  of 
alkali.     Some   of   the   unmedicated    superfatted   soaps  are  serviceable. 


70  THE  DISEASES  OF  CHILDREN 

Imported  castile  soap  is  an  old  favorite.  All  soap  must  be  used  cautiously, 
lest  the  skin  become  irritated. 

Towels  should  be  soft  and  absorbent.  Well-washed  and,  preferably, 
old  diaper-cloth  constitutes  one  of  the  best  materials.  Later  in  life 
Turkish  towelling  is  excellent.  Young  infants  should  be  patted  dry  and 
then  rubbed  with  the  palm  of  the  hand.  Later,  more  vigorous  drying 
with  the  towel  may  be  employed.  As  the  skin  of  the  infant  is  extremely 
sensitive,  dusting  it  with  some  absorbent  powder  after  bathing  is  advis- 
able, especially  in  all  the  folds  and  hollows.  For  this  purpose  talcum  or 
starch  is  useful.  The  addition  of  any  perfume  is  imnecessary  and  not 
advisable.  Occasionally  the  application  of  a  very  small  amount  of 
petrolatum  is  advantageous  if  the  skin  seems  too  dry. 

Local  Toilets. — The  eyes  of  the  young  infant  should  be  washed  daily 
with  boric  acid  solution  during  the  first  days  of  hfe.  They  should  be 
carefully  protected  against  excess  of  light  on  account  of  the  sensitiveness 
toward  it  which  exists  especially  in  the  new  born,  even  into  the  2d 
month  of  life  and  longer.  Later  in  infancy  and  childhood  care  must  still 
be  taken  that  the  child  does  not  injure  its  eyes  by  light  too  intense, 
insufficient,  or  badly  placed,  and  the  possibility  of  errors  of  refraction 
existing  must  be  borne  in  mind,  lest  serious  trouble  arise.  The  mouth 
of  the  young  infant  may  be  very  gently  washed  once  or  twice  a  day, 
with  absorbent  cotton  wrapped  around  the  little  finger  and  moistened 
with  sterilized  water,  but  this  should  be  done  with  the  greatest  caution, 
inasmuch  as  the  mucous  membrane  of  the  mouth  in  infancy  is  extremely 
sensitive.  Many  physicians  are  opposed  to  cleansing  the  mouth  at  all, 
unless  evidence  of  disease  develop. 

After  the  first  teeth  appear,  the  mouth  should  be  washed  and  the 
teeth  themselves  rubbed  with  a  moistened  cloth  morning  and  evening. 
When  most  of  the  temporary  set  are  cut,  a  small  tooth-brush  of  softened 
bristles  is  to  be  preferred  to  the  cloth.  Occasionally  the  use  of  a  carbonate 
of  lime  tooth  powder  on  the  brush,  or  even  of  powdered  pumice-stone 
applied  with  a  match  stick,  is  required  if  stains  appear  on  the  teeth. 
As  early  as  possible  older  children  should  be  taught  to  use  the  tooth- 
brush, and  to  draw  floss  silk  between  the  teeth  after  each  meal.  All 
decay,  even  of  the  first  set,  must  be  watched  for,  and  the  services  of  a 
dentist  obtained  at  once,  since  not  only  are  the  carious  teeth  unsightly, 
but  they  cause  toothache,  occasion  indigestion,  and  even  interfere  with 
the  eruption  of  the  second  set  in  the  proper  position.  It  is  especially  to 
be  remembered  that  the  permanent  anterior  molars  may  appear  and  even 
decay,  the  mother  meantime  mistaking  them  for  the  teeth  of  the  primary 
set.     (See  Dentition,  Vol.  I,  p.  37.) 

The  scalp  should  be  soaped  daily  for  some  months  at  the  time  of  the 
general  bath.  After  the  age  of  6  months,  however,  it  is  not  desirable  to 
use  soap  so  frequently,  lest  the  hair  be  made  dry  and  brittle.  In  child- 
hood soap  must  be  used  occasionally,  and  water  daily,  even  with  the 
longer  hair  of  girls.  The  first  brush  employed  should  be  of  camel's 
hair.  Later,  when  the  hair  grows  coarser,  a  stiffer  brush  is  required,  in 
order  to  remove  all  scahness.  Combs  should  always  be  used  with  great 
care,  and  only  for  parting  the  hair.  In  infancy  they  are  not  needed. 
Hair  should  be  trimmed  frequently,  and  even  in  the  case  of  girls  be  kept 
short  until  well  into  early  childhood. 

The  nails  of  the  fingers  should  be  cut  often  even  in  young  infants,  and 
be  kept  clean  with  a  soft  nail-brush.  The  toe-nails  should  never  have 
the  corners  rounded  off,  lest  ingrowing  follow. 


HYGIENE  71 

In  addition  to  the  daily  general  bath,  the  region  of  the  anus  and 
genitals  should  be  washed  with  water,  without  soap,  after  every  movement 
of  the  bowels  during  infancy.  If  there  is  much  irritation  of  the  skin, 
starch  water  may  be  substituted  with  advantage.  Daily,  too,  the  prepuce 
ought  to  be  fully  retracted  and  the  glans  washed  carefully  with  soap  and 
water.  Adhesions  between  the  prepuce  and  glans  are  very  common. 
These  are  usually  readily  broken  by  "stripping,"  if  this  procedure  is 
done  early.  (See  Adherent  Prepuce, Vol.  II,  p.  212.)  The  labia  majora 
should  be  separated  at  the  morning-bath  and  the  vulva  washed  carefully, 
the  direction  of  the  washing  being  toward  the  anus  in  order  to  avoid  as  far 
as  possible  the  forcing  of  feces  into  the  vagina. 

CLOTHING  1 

The  great  requisites  for  the  clothing  of  infancy  are  softness,  lightness, 
warmth,  looseness,  and  simplicity.  With  the  exception  of  the  diapers, 
woollen  or  partly  woollen  stuff  is  the  best  for  use  next  the  skin,  except  in 
hot  summer  weather,  or  for  infants  whose  skin  is  especially  sensitive, 
when  cotton,  silk  or  hnen  is  to  be  preferred.  The  weight  of  the  garments 
must,  of  course,  vary  with  the  season  of  the  year,  but  it  is  important  even 
in  winter  not  to  have  these  of  such  a  weight  that  perspiration  is  readily 
produced.  Extra  warmth  is  easily  obtained  by  the  use  of  sacks  and  the 
like,  which  can  readily  be  slipped  on  or  off  as  required.  More  children 
are  dressed  too  warmly  than  the  reverse.  The  underclothing  should 
cover  the  whole  body  except  the  head  and  the  hands  in  order  to  prevent 
sudden  chilling  after  perspiration.  There  should  be  no  pressure  which 
can  be  avoided.  All  petticoats  should  be  suspended  from  the  shoulders, 
and  should  be  simple  in  construction,  fastening  with  but  few  buttons 
or  with  a  narrow  ribbon.  The  old-fashioned  "pinning  blanket"  is  to  be 
condemned. 

First  Clothing  for  Infancy. — Considering  the  garments  more  in 
detail,  those  required  for  infancy  are  as  follows: 

1.  An  abdominal  hand,  which  is  of  flannel,  and  is  wrapped  about  the 
abdomen  next  to  the  skin.  It  holds  the  dressing  of  the  cord  in  place. 
After  the  falHng  of  the  cord  the  wearing  of  any  band  by  healthy  infants 
may  be  omitted  entirely,  but  it  is  generally  advised  to  replace  the  flannel 
band  by  a  knitted  circular  one  of  wool  or  of  wool  and  silk,  which  is  pinned 
to  the  diaper  and  supported  by  shoulder  straps. 

2.  A  diaper,  which  should  be  of  cotton  or  hnen  diaper-cloth  or  still 
better,  of  cotton  stockinet.  A  small  diaper  square  may  be  placed  within 
the  outside  diaper  in  such  a  position  that  it  will  receive  the  urine  and 
feces.  This  greatly  lessens  the  thickness  and  consequent  heating.  A 
rubber  or  other  impervious  cover  should  never  be  employed.  The  diapers 
should  be  changed  as  soon  as  wet  by  urine,  and  should  never  be  used  again 
until  after  they  have  been  washed.  If  this  precaution  is  not  observed 
chafing  is  likely  to  result.     No  soda  should  be  employed  in  washing  them. 

3.  High  crocheted  or  knitted  socks  of  silk  or  woollen  yarn. 

4.  A  loose  shirt,  long  sleeved  and  extending  below  to  the  band,  with 
the  opening  the  whole  length  of  the  front  and  fastened  by  small  fiat 
buttons,  or  overlapping  well  in  front  and  secured  by  tape.  This  should 
be  made  of  all  wool,  wool  and  cotton,  or  wool  and  silk,  and  be  of  thick- 

» Fuller  details  concerning  the  clothing,  the  layette,  etc.,  mav  be  found  in  the 
Author's  "The  Care  of  the  Baby,"  published  by  W.  B.  Saunders  Co.,  Phila. 


72  THE  DISEASES  OF  CHILDREN 

ness  varying  with  the  season.     In  the  hottest  summer  weather  it  may 
need  to  be  entirely  of  cotton. 

5.  A  sleeveless  petticoat  of  white  flannel  throughout,  made  in  one  piece 
from  neck  to  hem,  fastened  at  the  back  with  one  or  two  flat  buttons,  and 
extending  not  more  than  from  6  to  10  inches  (15  to  25  cm.)  below  the  feet. 
For  summer  the  petticoat  may  consist  of  a  flannel  skirt  attached  to  a 
loose  cambric  waist.  A  second  petticoat  of  cambric  is  often  worn  over 
the  first  to  prevent  the  flannel  showing  through,  but  this  is  unnecessary. 
In  very  warm  weather  the  flannel  petticoat  may  be  discarded. 

6.  A  slip  or  dress  of  nainsook  or  lawn,  loose,  with  long  sleeves,  and 
opening  at  the  back  like  the  petticoat  and  of  the  same  length,  or  only  a 
trifle  longer. 

A  once  popular  costume  known  by  various  proprietary  names  is  simi- 
lar to  that  described  except  that  the  knitted,  close-fitting  shirt  is  replaced 
by  a  long  loose  garment  very  similar  to,  and  almost  as  long  as,  the  petti- 
coat described,  but  with  long  sleeves.  This  shirt,  the  petticoat  and  the 
slip  may  be  fitted  together,  one  within  the  other,  and  then  all  three 
slipped  on  at  once,  thus  saving  considerable  turning  of  the  baby  back 
and  forth  while  being  dressed.  This  style  is  only  suitable  for  long 
clothing,  as  the  short  clothing  of  later  infancy  allows  too  much  air  to 
enter  under  the  loose  inner  shirt. 

Besides  the  garments  described  the  infant  needs  a  shawl  or  a  shoulder 
blanket  of  flannel,  to  be  used  as  a  protection  when  taken  out  of  the  room. 
Sometimes  a  thin,  knitted  worsted  sack  is  useful  if  the  room  happens  to 
be  cooler  than  usual.  This  allows  for  movement  of  the  arms.  A  flan- 
nelette wrapper  is  also  often  serviceable  to  put  on  before  the  child  has 
its  bath.  For  use  out-of-doors  there  is  required  for  winter  a  warm  long 
cloak,  warm  hood,  and  a  veil.  In  hot  summer  weather  only  a  cambric  or 
thin  silk  cap  is  required. 

At  night  the  child  should  be  dressed  in  a  fresh  diaper,  band  and  shirt, 
and  then  have  put  on  a  long,  roomy  nightgown  of  flannel,  canton  flannel, 
or  stockinet,  closing  with  a  drawing  string  at  the  bottom.  In  summer  it 
may  be  of  muslin,  and  need  not  be  fastened  below.  No  socks  are  re- 
quired at  night. 

Dressing  the  Cord. — Before  the  clothes  are  put  on  for  the  first 
time  the  stump  of  the  umbilical  cord  must  be  dressed.  It  is  dried  as  far 
as  possible,  powdered  with  bismuth,  boric  acid,  or  a  mixture  of  salicylic 
acid  and  starch  and  wrapped  thickly  in  salicylated  absorbent  cotton.  It 
is  then  laid  against  the  abdomen,  a  thin  compress  put  over  the  navel,  and 
the  binder  applied.  The  wrappings  of  the  cord  should  not  be  changed 
until  the  cord  falls,  provided  there  is  no  evidence  of  putrefaction.  The 
greatest  care  should  be  taken  to  prevent  the  soihng  or  wetting  of  the 
dressing.  The  ulcer  remaining  after  the  separation  of  the  cord  should 
be  dressed  with  powdered  boric  acid  applied  on  a  pad  of  absorbent 
cotton. 

Method  of  Dressing. — After  the  morning  bathing  and  drying,  the 
nurse,  still  holding  the  infant  lying  on  its  back  in  her  lap,  puts  the  band 
about  it,  or,  if  this  is  a  knitted  one,  slips  it  on  over  the  feet.  The  diaper 
is  next  placed  under  the  buttocks  and  the  ends  brought  around  in  front 
and  fastened  with  a  large  safety  pin  to  each  other  and  to  the  tab  of  the 
band.  Neither  band  nor  diaper  must  ever  be  so  tight  that  the  hand 
cannot  readily  be  shpped  between  it  and  the  skin.  The  socks  are  then 
drawn  on.  The  petticoat  is  next  adjusted  inside  of  the  dress,  and  the 
two  slipped  on  together  over  the  feet.    The  baby  is  now  laid  upon  its 


CLOTHING  73 

abdomen  and  these  garments  buttoned.     After  the  child  is  old  enough  to 
sit  alone  they  may  conveniently  be  slipped  on  over  the  head. 

Short  Clothes. — At  about  the  age  of  6  months,  the  choice  of  the 
time  depending  upon  the  season  of  the  year,  the  infant  is  put  into  short 
clothes.  Its  costume  then  consists  of  a  band,  diaper,  shirt,  petticoats 
and  sHp  similar  to  those  described,  except  that  the  skirts  reach  onh- 
nearly  to  the  ankle,  and  that  it  is  very  customary  now  to  make  the 
flannel  petticoat  alwaj^'s  with  a  muslin  waist  and  to  have  a  second  white 
petticoat  over  this.  In  addition,  the  child  requires  stockings  and  shoes. 
The  stockings  should  be  white,  in  order  to  avoid  any  action  of  irritating 
dyes,  and  made  of  silk,  woollen  or  partly  woollen  goods,  or,  in  hot  weather, 
of  cotton.  They  should  always  be  long  enough  to  reach  to  the  diaper, 
to  which  they  may  be  pinned,  and  should  be  loose  and  with  broad  toes, 
in  order  to  prevent  undue  constriction  of  the  feet. 


Fig.   13. — Imprint  of  Foot. 
From  life,  three-quarters  natural  size. 


Fig.   14. — Outline  of  Sole  of 
Shoe  to  Cover  Fig.  13. 


As  the  child  becomes  more  active  there  is  often  great  difficulty  in 
keeping  the  diaper  from  falling  off.  Careful  pinning  to  the  band  will 
obviate  this,  or  the  infant  may  wear  diaper  suspenders,  or  a  small  light 
waist  to  which  both  diaper  and  stockings  can  be  attached,  the  latter  by 
means  of  elastics  or  tapes. 

The  first  foot-covering  may  be  moccasins  of  kid,  chamois  leather  or 
felt.  When  the  child  begins  to  stand  and  creep  true  shoes  are  required. 
These  may  be  of  soft  kid,  with  kid  or  thin  leather  soles.  From  the  be- 
ginning they  should  be  rights  and  lefts,  conformed  to  the  natural  shape 
of  the  foot  and  with  broad  toes  and  without  heels  (Figs.  13  and  14). 

The  clothes  for  the  night  are  the  same  as  in  earlier  infancy.  For 
use  out-of-doors  the  coat  must  be  shorter  after  the  child  has  learned  to 
walk,  and  warm  knitted  or  Jersey  leggings  are  serviceable  in  winter. 

In  addition  to  the  articles  mentioned  the  infant  now  needs  quilted 
bibs  to  catch  the  overflowing  saliva.  Later,  a  serviceable  article  is  a 
creeping  apron.  This  should  be  large  and  roomy,  opening  at  the  back 
l)ut  closed  at  the  bottom,  except  for  the  apertures  for  the  legs  whicli 
fasten  just  below  the  knees.     Rompers  may  be  used  in  place  of  the  apron. 


74  THE  DISEASES  OF  CHILDREN 

Creeping  aprons  which  go  over  the  clothes  and  fasten  under  them  around 
the  waist  are  to  be  avoided,  as  they  allow  too  free  access  of  air  to  the  legs. 
Clothing  of  Childhood. — At  2  years  of  age,  or  less,  when  the 
diaper  can  be  dispensed  with,  the  clothes  of  childhood  replace  those  of 
infancy.  The  binder  is  abandoned,  if  it  has  been  worn  hitherto,  and  the 
clothing  consists  of  the  following  articles: 

1.  An  undershirt,  long-sleeved  and  high-necked,  of  material  as  before 
and  of  thickness  varying  with  the  time  of  year,  but  never  too  heavy. 

2.  Draicers,  close-fitting  merino  for  winter,  looser  and  of  muslin  for 
hot  summer  weather. 

3.  Stockings,  long  at  all  seasons.  Nothing  is  gained  and  much  damage 
may  be  done  by  dressing  little  children  in  short  stockings  and  leaving  the 
legs  bare. 

4.  A  white  muslin  skirt  without  a  waist. 

5.  A  loose,  high-necked,  sleeveless  waist  provided  with  buttons,  to 
which  the  stocking  supporters,  drawers,  and  skirt  can  be  attached. 
If  desired,  the  white  skirt  can  be  made  attached  to  a  waist  of  its  own, 
but  this  offers  no  advantage. 

6.  A  flannel  skirt  with  muslin  waist,  to  be  worn  in  winter. 

7.  A  dress,  which  commonly  indicates  by  its  style  the  sex  of  the  wearer. 

8.  Shoes,  which  should  have  the  posterior  portion  of  the  sole  made 
slightly  thicker — i.e.,  with  a  "spring" — when  the  child  is  3  or  4  years  old, 
but  which  should  have  no  true  heel  until  the  age  of  10  or  11  years. 

The  clothes  for  the  night  consist  of  a  shirt  and  night  drawers,  the  latter 
having  closed  feet  if  the  child  sleeps  restlessly  and  displaces  the  bed- 
clothes. The  material  may  be  cotton-flannel  or  stockinet  for  winter, 
and  muslin  for  summer.  Only  in  later  childhood  does  the  girl  begin 
to  use  a  nightgown  and  the  boy  a  night  shirt;  or  pajamas  may  be  worn 
by  either  sex.  When  out  of  doors  the  hood  should  be  worn  in  winter 
until  the  age  of  2  years  at  least. 

At  the  age  of  about  2  years  or  earlier  some  distinction  of  sex  is  made 
in  the  style  of  the  clothing,  and  by  3  or  4  years  the  boy  assumes  the  ordi- 
nary boy's  clothes.  The  girl  should  not  wear  corsets  or  corset-waists  as 
long  as  she  can  be  prevented  from  doing  so. 

SLEEP 

Hours  for  Sleeping. — A  healthy  infant,  in  the  first  few  weeks  of 
life,  sleeps  nearly  all  the  time;  in  all  from  19  to  21  hours,  rousing  only 
when  being  nursed,  washed  and  dressed,  or  when  it  is  hungry  or 
uncomfortable.  As  it  grows,  it  requires  less  and  less  sleep,  and  at  the 
age  of  2  months,  will  often  lie  awake  quietly  for  an  hour  or  so  at  a  time, 
and  show  a  tendency  to  some  regularity  in  the  hours  of  sleeping. 
By  the  age  of  6  months,  16  to  18  hours  are  required  daily;  by  1 
year,  14  to  16  hours;  at  2  to  3  years,  12  or  13  hours;  at  4  to  5 
years,  10  or  11  hours;  at  12  to  13  years,  9  or  10  hours.  Sleep 
during  infancy  is  always  easily  disturbed  by  hght,  noise,  and 
handling.  In  children  it  is  deeper.  From  the  beginning,  the  child 
should  be  taught  to  sleep  at  regular  times,  and  to  be  put  to  sleep 
in  proper  ways.  Walking  the  floor,  rocking,  singing  to  sleep,  and  the 
like,  are  entirely  unnecessary.  They  establish  the  child  in  a  bad  habit, 
and  make  a  slave  of  the  mother.  If  the  infant  is  certainly  well, 
it  should  be  put  in  its  bed  at  the  time  for  sleep  and  left  alone  in  the 
room.    If  it  wakes  in  the  night  it  must  not  be  taken  from  its  bed  unless 


SLEEP  75 

it  is  time  to  nurse  it,  or  the  diaper  requires  changing.  Knowing  no  other 
method  it  will  soon  content  itself  with  this.  Allowing  a  child  to  go  to 
sleep  while  nursing  at  the  breast  or  bottle  and  before  it  has  finished 
should  be  prevented  as  far  as  possible.  Before  the  age  of  3  or  4  months 
the  baby  is  made  ready  for  bed  at  5.30  to  6  p.m.,  and  should  rouse  but 
once  or  twice  during  the  night.  During  the  day  it  may  sleep  at  first  all 
it  will,  but  must  be  wakened  for  feeding  when  this  is  due.  This  is  a 
matter  of  importance,  as  otherwise  there  can  be  no  regularity  in  the 
feeding  hours.  After  this  age  it  may  be  put  to  bed  at  from  6  to  7  p.m., 
be  wakened  at  9  or  10  for  feeding,  as  long  as  this  is  required,  and  be 
trained,  as  soon  as  possible,  to  sleep  without  further  rousing  until  6  or 
7  A.M.  It  will  now  be  awake  for  longer  periods  in  the  day  time,  and  by 
the  age  of  6  months  or  earlier  will  content  itself  with  a  nap  in  the  morning 
of  from  \}y'2  to  2  hours  or  more,  and  a  shorter  one  in  the  afternoon.  The 
nap  in  the  day  should  be  of  regular  length,  and  the  child  not  allowed  to 
sleep  over  the  time  for  feeding.  At  the  age  of  from  1  to  2  years  the 
afternoon  nap  may  be  omitted,  unless  the  child  seems  to  require  it; 
the  morning  nap  lasting  usually  2  hours.  After  2  years  the  morning 
nap  may  be  shortened  to  3^^  or  1  hour.  The  child  should  continue  to 
take  it  up  to  the  age  of  4  years,  if  possible.  Children  of  4  years  should 
go  to  bed  at  8  p.m.  or  earlier,  and  the  time  be  gradually  changed  to 
9  P.M.  by  the  age  of  10  to  12  years. 

When  the  infant  begins  to  take  a  regular  morning  nap,  it  is  best  that 
it  should  be  undressed  for  it,  and  be  put  to  bed  as  though  it  were  night. 
Often  the  morning  dressing  may  conveniently  be  delayed  until  after  the 
nap,  and  the  morning  bath  then  given.  The  hour  for  the  morning  nap 
will  depend  partly  on  the  disposition  of  the  child,  and  partly  on  the  season 
of  the  year.  A  portion  of  the  day  should  be  selected  which  will  not 
interfere  with  the  daily  outing.  A  certain  degree  of  latitude  is  there- 
fore to  be  allowed  in  the  fixing  of  the  time  and  in  the  necessary  duration 
of  sleep.  The  two  great  desiderata  sought  for  are,  first,  regularity,  and, 
second,  the  obtaining  of  the  long  quiet  sleep  at  night. 

When  asleep,  the  child  may  assume  any  position  most  comfortable  to 
it.  In  the  case  of  young  infants  the  necessity  of  the  position  being 
changed  from  time  to  time  must  not  be  forgotten. 

Place  to  Sleep. — -The  infant  should  not  sleep  in  the  bed  with  its 
mother.  There  is  danger  of  her  overlying  it,  to  say  nothing  of  the 
constant  temptation  to  nurse  the  child  too  often.  It  is  Hable,  too,  to 
receive  too  little  fresh  air,  as  g,  result  of  getting  its  head  under  the  bed- 
clothes. The  first  bed  generally  used  is  the  bassinette.  It  consists  of  a 
wicker-basket  with  high  sides,  lined,  best  unprovided  with  curtains,  and 
with  or  without  a  hood  at  one  end.  It  should  be  high  enough  above  the 
floor  to  escape  the  draughts.  A  cradle  may  be  used  instead,  but  should 
be  one  not  capable  of  being  rocked.  The  bassinette  is  preferable  to  the 
crib  for  the  early  months  of  life,  as  it  gives  the  child  more  support  and 
keeps  it  warmer.  At  the  age  of  8  or  9  months  and  up  to  that  of  5  years  a 
crib  is  used.  This  should  have  sides,  which  let  down  on  hinges  or  slides 
and  are  high  enough  to  prevent  the  child  falling  out,  and  be  provided 
with  a  woven-wire  mattress.  A  very  serviceable  device,  especially  for 
sleeping  out-of-doors  in  summer,  is  the  baby  cariole  (Fig.  15). 

The  bedding  for  the  bassinet  and  crib  is  the  same.  There  should  be, 
namely,  a  thin,  hair-mattress,  a  rubber  cloth,  in  the  case  of  infants, 
to  go  over  this,  and  a  doul^lcd  sheet.  Sometimes  a  quilted  bed-cover  may 
be  put  under  the  sheet  to  increase  the  warmth   in   winter  time.    The 


76 


THE  DISEASES  OF  CHILDREN 


pillow  should  be  small;  a  soft,  thin,  feather  pillow  with  a  linen  pillow 
slip.     A  curled-hair  pillow  may  be  substituted  in  summer  if  desired. 

The  coverings  of  the  child  when  in  bed  should  consist  of  a  muslin 
sheet,  as  many  light  blankets  as  needed,  and  a  light  spread.  A  down 
quilt  is  an  advantage  in  winter.  Owing  to  the  restless  sleep  of  so  many 
children,  some  form  of  bed-clothes-fastener  is  desirable.  A  great  many 
children  are  covered  far  too  warmly  at  night,  with  the  result  that  sleep 
is  rendered  restless,  free  perspiration  occurs  and  cold  is  very  easily  taken. 

It  is  theoretically  better  that  the  infant  from  the  beginning  sleep  in  a 
separate  room  from  its  mother,  under  the  care  of  a  competent  nurse. 
Often  this  cannot  be  arranged  for  many  reasons.  After  the  age  of  a  year, 
it  certainly  should  have,  if  possible,  a  separate  room  at  night.  Older 
children  are  preferably  placed  in  individual  beds. 


Fig.   15. — Baby  Cabiole. 


AIRING,  EXERCISE,  AMUSEMENTS,  AND  TRAINING 

Airing. — With  regard  to  airing,  no  absolute  rule  can  be  formulated. 
At  2  weeks  of  age  the  nurse  may  take  the  infant  into  another  room  of 
a  somewhat  cooler  temperature,  proper  protection  being  given  by  dress- 
ing it  in  its  out-door  clothing.  By  the  age  of  1  month  it  may  be  taken 
into  the  open  air  for  10  or  20  minutes,  and  longer  on  subsequent  visits, 
until  finally  it  is  out  of  doors  2  or  3  hours  or  more  daily.  This  applies 
to  the  spring  and  autumn,  but  in  warm  summer  weather  it  may  go  out 
even  at  an  earlier  age,  wliile  in  midwinter  it  cannot  do  so  until  it  is 
3  or  4  months  old  or  possibly  even  later.  In  place  of  this  it  may  have  its 
daily  airing  in  a  room,  the  windows  of  which  have  been  open  for  a  short 
time,  but  closed  just  before  the  child  enters  it.  Later,  when  accustomed 
gradually  to  the  outer  air,  the  windows  may  be  left  open  during  its  pres- 
ence. When  possible,  autumn  babies  should  be  gotten  out  of  doors  be- 
fore the  winter  sets  in.  If  this  cannot  be  managed,  the  use  of  the  room 
with  open  windows  may  often  be  advantageously  continued  until  spring. 
The  important  matter  is  that  the  infant  shall  be  accustomed  gradually 
to  the  cool  air,  and  that  as  soon  as  possible  it  shall  have  an  abundance  of 
fresh  out-door  air. 

It  is  a  mistake  to  take  an  infant  into  the  open  air  every  day  no  matter 
what  the  character  of  the  weather.  Very  damp,  windy,  or  intensely  cold 
days  are  to  be  avoided  and  the  outing  in  the  room  with  open  windows 
employed  instead.  Always  the  condition  of  the  hands  and  feet  and  the 
color  of  the  face  are  to  be  watched,  and  the  airing  stopped  if  the  infant 
shows  the  least  chilliness. 


AIRIXG,  EXERCISE,  AMUSEMENTS,  AND  TRAINING  77 

Although  the  bed  is  usually  a  better  place,  there  is  no  reason  why  a 
child  may  not  sleep  out  of  doors  in  warm  weather,  or  even  in  cold  if  it 
is  well  protected  and  its  condition  carefully  watched.  Some  children 
invariably  fall  asleep  when  taken  out.  Certainly  in  any  case  the  sleeping- 
room  should  have  fresh  air  in  abundance. 

The  first  going  out  should  be  in  the  nurse's  arms,  as  this  gives  greater 
protection  and  warmth.  After  the  age  of  3  or  4  months,  depending  upon 
the  season,  a  perambulator  should  be  used.  This  should  have  a  sunshade 
or  hood  which  is  lined  with  some  dark  color,  such  as  green  or  brown, 
to  avoid  injury  to  the  ej^es  by  the  reflected  or  transmitted  light.  The 
infant  should  recline  in  the  coach,  but  after  the  age  of  7  or  8  months 
may  sit  supported  a  portion  of  the  time,  care  being  taken  that  the  back 
does  not  become  fatigued. 

Exercise.- — -After  the  first  2  weeks  of  life  the  infant  begins  to  move 
its  arms  and  legs  freely.  It  can  be  assisted  in  this  by  having  the  clothing 
loose  and  not  too  long.  At  2  weeks  it  should  be  exercised  by  being 
systematically  carried  about  in  the  arms  several  times  a  day,  lying  on 
a  pillow  in  order  to  give  support  to  the  spine.  At  the  age  of  1  month  the 
pillow  may  be  discarded.  At  3  or  4  months  the  infant  should  be  carried 
about,  seated  upright  in  the  nurse's  arm  with  her  hand  supporting  its 
back.  It  should  never  be  held  always  on  one  arm,  or  lateral  curvature 
of  the  spine  is  liable  to  develop.  The  carrying  about  by  the  nurse  is  a 
matter  of  vital  importance.  Infants  who  he  too  much  in  their  cribs  do  not 
thrive  as  they  should.  At  about  6  months  of  age  it  may  be  propped  with 
pillows  in  a  sitting  position,  but  only  for  a  little  while  at  a  time.  From 
the  age  of  3  or  4  months  on  the  cliild  may  be  placed  at  times  upon  a 
thick  blanket  or  mattress,  spread  upon  the  floor  or  elsewhere,  securely 
out  of  draughts.  Here  it  can  make  all  movements  of  which  it  is  capable, 
and  has  also  a  good  chance  later  to  creep  as  soon  as  it  is  able.  The  great 
likelihood  of  the  existence  of  draughts  upon  the  floor,  especially  in  cold 
weather,  must  never  be  forgotten.  Children  who  have  learned  to  creep 
or  walk  will  take  all  the  exercise  they  need.  The  baby  should  take  its  own 
time  to  learn  to  walk,  and  no  appliances  to  aid  it  in  this  are  advisable. 
The  legs  should  be  carefully  watched  for  evidence  of  bowing.  (For  the  age 
for  creeping  and  walking,  see  p.  65.)  The  perambulator  or  some  form 
of  baby-coach  must  still  be  used  for  most  of  the  airing  until  the  age  of 
2V^  or  even  3  years,  the  child  being  allowed  to  walk  when  it  desires,  but 
for  not  too  long  at  a  time,  lest  fatigue  ensue  or  the  arch  of  the  foot  be 
overstrained. 

Various  different  forms  of  exercise  will  be  advisable  as  the  child  grows 
older,  in  order  to  bring  into  play  different  muscles  of  the  body  and  to 
preserve  symmetry  in  development.  Little  restraint  need  be  imposed 
unless  the  child  is  delicate,  or  of  the  nervous  and  excitable  nature  which 
disposes  it  to  exercise  to  the  point  of  exhaustion.  All  out-door  sports 
should  be  encouraged  for  both  sexes.  The  tricycle  and  similar  apparatus 
can  be  used  early,  and  later  the  bicycle.  Swimming,  skating,  riding, 
tennis,  and  the  like  are  all  excellent.  Jumping  rope  is  harmless  unless 
much  overdone.  In  winter,  especially  in  cities,  it  is  often  difficult  to 
obtain  sufficient  exercise.  Dancing  and  work  in  a  gymnasium  now  be- 
come the  best  substitutes. 

Training  and  Amusements. — Teaching  the  control  of  the  bowels 
and  bladder  should  l)e  coinmenced  early,  certainly  by  the  age  of  3  months. 
If  the  infant  is  systematically  supported  on  a  receptacle  at  the  time  wlien 
the  evacuation  of  the  bowels  is  found  most  likely  to  occur,  generally  after 


78  THE  DISEASES  OF  CHILDREN 

a  meal,  much  may  be  accomplished.  The  control  of  the  bladder  is  more 
difficult  to  acquire,  but  even  before  the  end  of  the  1st  year  some  infants 
can  be  taught  it,  at  least  during  the  waking  hours.  Patience  and  perse- 
verance are  required,  and  punishment  at  any  age  is  out  of  the  question. 

Amusements  begin  early,  and  those  may  gradually  be  chosen  which 
educate  the  mind  to  a  certain  extent.  Yet  the  training  of  the  mind 
must  always  hold  a  secondary  place,  lest  overstimulation  of  it  result. 
In  fact  all  amusements  which  cause  much  excitement  are  to  be  avoided, 
and  this  is  especially  true  if  they  have  been  permitted  just  before  bed- 
time. Insomnia  is  a  natural  result.  By  the  age  of  5  or  6  months  a 
rattle  or  a  rubber  doll  wiU  be  enjoyed.  Later  more  toys  are  needed  for 
the  house,  and  others  to  be  used  out  of  doors.  Mental  and  moral  train- 
ing can  soon  be  commenced  by  using  judgment  in  the  selection  of  the 
amusements.  Thus  the  constant  providing  of  new  toys  teaches  a  child 
discontent,  lack  of  valuation  and  lack  of  care  of  those  which  it  possesses 
as  well  as  lack  of  neatness.  Pernicious,  too,  is  the  constant  effort  of  the 
mother  to  amuse  the  child,  since  it  should  be  taught  to  amuse  itself. 
Many  toys  may  be  chosen  which  instruct,  such  as  picture  books,  Noah's 
arks,  picture  blocks,  and,  later,  lettered  blocks. 

The  inculcating  of  obedience,  unselfishness,  absence  of  self-conscious- 
ness, fearlessness,  and  general  kindhness  to  all  created  things  can  hardly 
be  commenced  too  early.  There  is  no  hurry  about  teaching  a  child  to 
talk,  but  the  use  of  "baby-talk"  in  addressing  it  is  alM^ays  to  be  avoided. 

Girls  and  boys  should  play  together  and  at  the  same  games  as  long 
as  disposed.  They  have  a  natural  disposition  to  do  this  until  the  age 
of  9  or  10  years  is  reached  unless  they  have  been  taught  to  do  differently. 
Yet  a  careful,  unobserved  supervision  should  early  be  kept  over  the  play, 
since  sexual  innocence  in  early  years  is  by  no  means  so  common  as  often 
assumed. 

School  Life. — Most  important  is  it  that  the  mental  powers  shall 
not  be  forced.  Precocity  is  not  desirable.  The  kindergarten  is  excel- 
lent for  young  children,  and  much  instruction  is  gained  in  this  way. 
Yet  even  this  is  sometimes  too  stimulating.  There  is  nothing  gained  in 
having  a  child  learn  to  read  before  the  age  of  6  years.  Even  at  this  period 
the  hours  spent  in  school  are  generall}^  far  too  long.  From  3  to  4  hours 
daily  from  the  age  of  6  or  7  up  to  that  of  10  years  are  quite  enough. 
Ocular  defects,  lateral  curvature  of  the  spine,  loss  of  appetite,  poor  gen- 
eral health  and  nervous  irritability  are  common  results  of  improper 
school  life. 

As  to  the  fittings  of  the  school-room,  the  chairs  employed  should  be 
low  enough  to  allow  the  feet  to  rest  comfortably  on  the  floor,  and  should 
be  so  constructed  that  they  support  the  lower  part  of  the  back.  The  desks 
must  not  be  high,  or  the  child's  eyes  are  brought  too  close  to  its  work, 
and  the  spine  is  liable  to  be  distorted  when  it  writes.  The  light  must  be 
so  disposed  that  there  is  no  glare  in  front,  and  that  trying  cross  lights  are 
done  away  with.  There  should  be  at  least  300  cubic  feet  (8.49  cubic 
metres)  of  air  space  for  each  individual,  and,  in  addition,  the  air  should 
be  constantly  and  completely  changed  by  ventilation  several  times 
an  hour. 

NURSERY 

Day  Nursery. — Inasmuch  as  the  baby  spends  so  much  of  its  time  in 
the  nursery,  the  position  of  this  in  the  house  is  of  the  greatest  importance. 
It  should  be  selected  with  reference  to  winter  rather  than  summer,  since 


NURSERY  79 

the  child  will  be  out  of  doors  so  much  of  the  time  in  the  latter  season.  It 
ought  to  be,  if  possible,  the  brightest,  airiest  room  in  the  house.  The 
preferable  exposure  is  south,  or,  if  this  is  not  obtainable,  east  rather  than 
west  on  account  of  the  morning  sun.  A  corner  room  with  south  and  west 
windows  is  ideal.  The  windows  should  not  extend  to  the  floor,  since  the 
children  readily  take  cold  as  a  result  of  getting  too  close  to  them.  Other 
things  being  equal,  the  nursery  should  be  on  the  third  floor,  if  this  is  not 
directly  under  the  roof,  as  it  is  more  out  of  the  way  here.  It  should  have 
at  least  500  cubic  feet  (14.16  cubic  metres),  and  preferably  1000  cubic 
feet  (28.32  cubic  metres)  of  air  space  for  every  person  occupying  it,  and 
in  addition  should  be  properly  ventilated  by  a  constant  and  abundant 
supply  of  fresh  air.  Window  ventilation  of  some  form  accomphshes  this 
fairly  well  yet  with  some  danger  of  draughts.  Probably  the  best  of  all 
ventilation  in  houses  not  especially  built  to  secure  it  in  other  ways, 
is  obtained  by  an  open  fireplace  with  a  fire  burning.  Sometimes  it  is 
safer  to  ventilate  from  an  adjoining  room.  In  addition  to  the  constant 
ventilation  the  room  should  be  aired  thoroughly  with  wide-open  windows 
once  or  twice  a  day  at  times  when  it  is  unoccupied. 

Draughts  upon  the  floor  nearly  always  exist  in  cold  weather  even  when 
the  windows  are  closed,  the  air  being  chilled  by  the  cold  panes.  Double 
sashes  will  prevent  this  to  a  great  degree,  but  in  very  cold  weather  it  is 
better  to  keep  the  child  away  from  the  windows  and  even  off  of  the  floor. 

In  the  line  of  heating  probably  nothing  equals  a  hot-air  furnace, 
especially  if  the  air  comes  from  over  hot-water  pipes,  as  it  is  easily  con- 
trolled and  supplies  fresh  warmed  air  from  without.  A  fireplace,  or  a 
properly  constructed  coal  stove,  is  effective  in  the  same  way,  but  gives 
an  uneven  heat  and  is  less  controllable.  Gas-stoves  or  oil-stoves  should 
never  be  used  unless  provided  with  smoke-pipes  connected  with  the 
chimney.  The  only  exception  is  for  the  rapid  heating  of  the  room  be- 
fore the  bath,  when  this  can  be  accomplished  in  no  other  way.  Steam 
and  hot  water  radiators,  though  serviceable  heating  apparatus,  afford 
no  ventilation  whatever. 

All  hot  registers,  fireplaces  and  the  like,  and  all  lights,  should  be  so 
guarded  that  a  child  cannot  possibly  burn  itself.  A  couple  of  thermome- 
ters should  be  placed  in  different  parts  of  the  nursery,  one  of  them 
near  the  floor,  since  it  is  in  here  that  so  much  of  the  time  is  passed.  The 
temperature  of  the  nursery  should  be  as  uniform  as  possible  at  from  66° 
to70°F.  (18.9°to21.1°C.). 

The  furnishings  of  the  nursery  may  be  attractive,  yet  simple  and 
arranged  with  a  view  to  cleanliness.  The  floor  should  be  well  made, 
the  cracks  stopped,  and  the  whole  painted  or  varnished,  but  not  with  a 
slippery  finish.  Carpeting  in  the  form  of  one  or  several  rugs  is  required. 
These  should  not  be  tacked  down.  The  walls  and  ceiling  are  best  painted. 
If  paper  is  used  one  must  be  sure  it  contains  no  poisonous  coloring  matter, 
Windows  should  have  no  heavy  curtains,  and  should  be  fitted  with  bars 
to  avoid  danger  of  falling  out.  The  doorway  should  have  a  swinging  or 
sliding  gate  to  keep  the  child  from  the  stairway.  The  furniture  of 
the  nursery  is  better  if  not  upholstered.  Chairs  with  projecting  rockers 
and  furniture  with  sharp  corners  are  to  be  avoided.  Among  the  articles 
of  furniture  is  the  "nursery  chair"  on  which  the  infant  is  placed  when  it 
is  to  empty  its  bladder  or  bowels,  and  only  then.  Portable  screens  are 
very  useful.     A  nurseiy  refrigerator  is  a  great  convenience. 

The  nursery  must  be  kept  scrupulously  clean  and  neat.  No  wet 
diapers  are  to  be  kept  hanging  about,  and   no  empty  nursing  bottles 


80  THE  DISEASES  OF  CHILDREN 

or  empty  dishes  left  in  it.  A  stationary  washstand  may  be  in  the  room, 
provided  that  one  is  sm-e  that  the  trapping  is  perfect,  and  that  there  is 
no  danger  of  the  entrance  of  sewer-gas. 

Night  Nursery. — Although  a  room  set  apart  especially  for  the  night 
is  not  an  essential,  yet  it  is  a  great  convenience  when  there  are  several 
small  children  in  the  family.  The  requirements  are  the  same  whether 
this  separate  room  or  the  day  nursery  is  used,  and  the  infant  should 
sleep  here  whether  at  night  or  during  its  daily  naps  unless  the  sleeping 
in  the  daytime  is  done  out  of  doors.  The  heating  and  ventilation  are 
provided  as  in  the  day  nursery,  and  the  room  should  be  thoroughly 
aired  and  then  warmed  again  after  each  occasion  on  which  it  is  used. 
There  must  always  be  some  arrangement  for  heating  food  at  night, 
such  as  an  alcohol-stove  or  small  gas  or  electric  heater.  The  temperature 
of  the  room  should  be  about  65°  or  70°F.  (18.3°  or  21.1°C.)  during  the 
early  weeks  and  later  from  50°  to  65°F.  (10°  to  18.3°C.).  A  window 
should  be  partly  open  as  a  rule,  but  it  is  not  wise  to  have  it  widely  open 
during  very  cold  weather.  Light  should  not  be  allowed  to  burn  all 
night.  If  it  is  necessary  to  have  this  on  occasions,  a  small  wax  night 
light  is  excellent.  When  it  can  be  obtained,  nothing  equals  electric 
light,  as  it  consumes  none  of  the  oxygen.  Small  shaded  electric  lamps  can 
be  obtained.  If  oil  lamps  are  used  for  lighting  before  the  child  is  put 
to  bed  they  must  be  out  of  harm's  way  where  they  cannot  be  upset. 
The  beds  must  be  carefully  placed  out  of  the  way  of  draughts.  The  use 
of  folding  screens  is  an  aid  to  this  end.  If  the  child  is  bathed  and  dressed 
in  the  night  nursery  the  temperature  of  the  room  should  be  elevated  to 
70°F.  (21.1°C.)  before  the  toilet  begins. 

Sick  Room. — In  the  case  of  ordinary  slight  ailments  no  special  room  is 
required,  one  of  the  nurseries  being  generally  employed ;  but  in  more  ser- 
ious illnesses,  or  where  special  quiet  is  demanded,  the  room  selected  should 
be  away  from  sources  of  disturbance.  Numerous  bottles  of  medicine 
should  not  be  allowed  to  stand  about.  Not  only  is  this  unsightly,  but 
there  is  danger  of  giving  the  wrong  drug.  Ventilation  is  very  impor- 
tant, yet  sometimes  difficult  to  obtain  satisfactorily  on  account  of  the 
danger  of  draughts  in  certain  diseases.  Sometimes  it  is  necessary  to 
ventilate  entirely  from  an  adjoining  room  where  the  air  is  kept  fresh 
and  warmed. 

The  special  requirements  of  the  sick  room  for  infectious  diseases  will 
be  described  in  considering  that  subject.  (See  Infectious  Diseases,  p. 
307.) 

NURSES 

The  Nurse=maid. — Two  of  the  greatest  requisites  in  a  nurse-maid 
are  intelligence  and  docility.  Consequently  the  nurse-maid  should  be 
preferably  in  middle  life,  but  better  young  than  old.  The  old  nurse- 
maids are  commonly  so  opinionated  that  their  methods,  generally  bad 
ones,  cannot  be  changed.  There  are,  of  course,  exceptions  to  this. 
The  maid  should  be  neat,  strong,  healthy  and  of  loving  and  patient 
disposition.  No  matter  how  faithful  and  efficient  she  may  seem,  no 
mother,  even  the  inexperienced,  dare  give  up  her  own  constant  supervision. 

The  Trained  Nurse. — The  nurse  trained  specially  for  the  care  of 
infants  and  children  during  illness  will  be  of  the  greatest  service  to  the 
patient,  the  family,  and  the  physician,  if  with  a  proper  knowledge  of 
nursing  she  combine  a  special  recognition  of  the  responsibilities  and 
relationships  which  the  nursing  of  a  sick  child  creates.     If  she  is  not  so 


NURSES  81 

qualified  she  may  do  more  harm  than  good.  It  is  the  physician's  duty 
to  select  carefully  the  nurse  adapted  for  this  service  and  to  supervise  the 
nursing  constantly.  A  few  of  the  qualifications  required  may  be  passed 
in  review: 

1.  The  nurse  should  be  accustomed  to  and  have  a  fondness  for  little 
children.  Nothing  is  more  exacting  and  trying  than  the  nursing  of  sick 
children,  and,  unless  there  exists  a  special  native  fitness  and  hking  for  it, 
a  nurse  should  not  undertake  it. 

2.  She  should  be  quick  to  recognize  and  prompt  to  report  important 
symptoms.  Onl}^  careful  training  and  inborn  acuteness  of  observation, 
combined  with  good  judgment,  can  give  a  nurse  this  invaluable  quality. 

3.  She  should  be  quiet,  gentle,  firm,  resourceful,  and  comforting. 
The  influence  of  such  a  nurse  upon  the  mental  state  of  a  nervous  infant 
and  nervous  mother  is  often  most  remarkable. 

4.  The  nurse  must  carry  out  the  physician's  directions  implicitly 
and  without  criticism  before  the  family;  yet  know  when  emergenc}^ 
justifies  and  compels  a  failure  to  do  this.  Unless  she  has  this  quality  her 
actions  are  too  much  those  of  an  automaton. 

5.  She  must  not  be  imposed  upon  by  the  family.  No  nurse  can  do 
good  work  who  is  exhausted  by  the  nursing  of  a  fretful,  ill  infant,  in  which 
she  is  given  no  opportunity  for  systematic  rest.  Families  are  prone  to 
forget  this,  and  for  the  sake  of  the  patient  the  physician  should  see  that 
matters  are  properly  arranged. 

6.  On  the  other  hand,  the  nurse  must  be  willing  and  helpful,  and  avoid 
making  her  presence  a  burden.  The  installing  of  a  nurse  necessarily 
adds  to  the  responsibilities,  expenses,  and  cares  of  the  manager  of  the 
household,  and  mothers  often  dread  it  with  reason.  If  the  nurse  seems 
to  need  some  one  speciallj^  to  wait  upon  her,  as  is  often  the  case;  is  not 
quick  to  offer  to  prepare  and  serve  special  food  for  the  child ;  is  unwilling 
to  take  the  ordinary  care  of  the  room,  or  to  take  the  place  of  the  mother 
in  giving  a  convalescent  child  its  outdoor  airing  in  its  coach ;  is  displeased 
if  she  is  not  taken  fully  into  the  family  social  life,  as  at  meals  or  in  the 
evenings,  she  fails  to  recognize  the  dignit}'  and  duties  of  her  profession, 
and  is  not  a  suitable  caretaker  for  a  sick  child.  Inasmuch  as  these  faults 
are  all  too  common,  the  physician  must  acquaint  himself  with  conditions 
and  correct  those  which  are  wrong. 


CHAPTER  Til 
BREAST-FEEDING 

Advantages.- — The  general  superiority  of  breast-feeding  can  hardly 
be  questioned.  Statistics  show  that  the  mortality  of  breast-fed  children 
in  the  1st  year  is  much  less  than  that  of  those  fed  on  the  bottle.  (See 
Mortality,  p.  212.)  In  fact  the  average  probability  of  death  in 
the  1st  year  in  artificially  fed  infants  as  compared  with  the  breast- 
fed may  be  placed  at  5  :  1.  The  figures  of  Camerer^  and  others  demon- 
strate, too,  that  infants  fed  artificially  do  not  as  a  class  gain  as  rapidly 
in  the  1st  year  as  those  breast-fed.  Further,  the  interesting  studies  of 
Rose^  upon  164,000  individuals  showed  that  the  deleterious  influence 
of  bottle-feeding  could  often  be  detected  even  in  adult  life!  Although 
artificial  feeding  carefully  carried  on  will  undoubtedly  give  much  better 
results  than  statistics  indicate,  yet  the  superiority  of  breast-feeding,  as  a 
rule,  remains  unquestionable.  This  is  a  natural  and  unavoidable  result 
of  the  fact  that  other  mammalian  milks  are  in  a  sense  foreign  substances 
and  cannot  be  made  otherwise.  Certainly  every  effort  should  be  put 
forth  to  have  the  infant  breast-fed  for  the  first  3  months  of  life  at  least, 
by  which  time  a  fair  start  has  been  obtained,  and  success  with  artificial 
feeding  is  more  likely  to  follow. 

Ability  of  Mothers  to  Nurse.- — -The  long-continued  propaganda 
for  artificial  feeding,  especially  with  proprietary  foods,  had  in  the  course  of 
years  the  natural  sequence  that  breast-feeding  in  many  localities  became 
comparatively  uncommon,  or  at  least  continued  for  a  very  short  time. 
I  have  reviewed  the  subject  rather  extensively  elsewhere,^  and  a  few 
illustrative  statistics  may  be  quoted  from  those  publications.  Conditions 
vary  greatly  with  the  locality.  In  Japan  breast-feeding  is  the  rule. 
In  Greenland  artificial  feeding  is  scarcely  known,  and  among  the  Esquimo 
of  Alaska  there  is  no  cow's  milk  available,  and  infants  are  often  nursed 
for  from  2  to  3  years.  On  the  other  hand,  Nordheim^  found  that  only 
3.6  per  cent,  of  the  women  studied  in  Munich  nursed  for  over  3  months, 
and  only  0.8  per  cent,  for  over  6  months.  Neumann^  stated  that  55.2  per 
cent,  of  the  children  seen  by  him  in  Berlin  were  nursed  in  1885  and  only 
31.4  per  cent,  in  1890;  and  Kophk  in  New  York''  found  only  10  per  cent, 
in  private  practice  fed  on  the  breast  alone. 

Much  of  this  apparent  inability  is  probably  unwilKngness  and  a  lack 
of  teaching  by  the  profession,  and  the  indications  are  that  with  the  in- 
creasing urging  by  physicians  upon  mothers  regarding  the  importance 
of  breast-feeding  the  frequency  is  now  again  increasing.  An  investiga- 
tion by  MitchelF  upon  2819  mothers  in  Philadelphia  showed  that  the 
average  duration  of  lactation  was  6  months.     Negris*  in  Graz  found  a 

1  Jahrb.  f.  Kindcrh.,  1893,  XXXVI,  249. 

2  Deutsch.  Monatsschr.  f.  Zahnkunde,  1905,  XXIII,  13.    Ref.  Ziegenspeck.Verhandl. 
Gesellsch.  f.  Geburtsh.  u.  Gynalc,  1907,  XII,  829. 

3  New  York  Med.  Jour.,  1909,  Dec.  4;  Journ.  Amer.  Med.  Assoc,  1912,  LIX,  1874, 
^  Arch.  f.  Kinderh.,  1901,  XXXI,  89. 

6  Deut.  med.  Wochenschr.,  1902,  XXVIII,  795. 
*  Journ.  Amer.  Med.  Assoc,  1912,  LVIII,  75. 
'  Jour.  Amer.  Med.  Assoc,  1916,  LXVI,  1690. 
8  Wien.  klin.  Wochenschr.,  1905,  XVIII,  459. 

82 


BREAST-FEEDING  83 

physical  disability  in  only  10  per  cent,  of  the  women  in  the  obstetrical 
clinic.  Mme.  Dluski^  observed  that  99  per  cent,  of  the  women  seen 
in  the  obstetrical  clinic  of  Pinard  in  Paris  could  nurse  at  least  for  a  time ; 
and  Blacker-  in  London  found  only  2.5  per  cent,  of  the  mothers  with  a 
physical  inability  to  nurse.  That  the  general  ability  can  increase  through 
the  training  of  the  people  is  indicated  by  the  experience  of  Jaschke^ 
who  observed  that  while  in  1904,  64.01  per  cent,  of  the  infants  in  Heidel- 
berg were  breast  fed,  in  1907,  86. 14  per  cent,  were  so  fed,  and  in  some  years 
97.22  per  cent.  The  frequency  of  maternal  nursing  is,  however,  far  from 
what  could  be  desired;  and  it  is  undoubtedly  true  that  the  nervously 
organized  mother  of  the  upper  classes  often  is  unable  to  nurse  her  infant 
in  spite  of  her  strong  desire  to  do  so.  Yet  in  numerous  cases  it  is  the  ill- 
considered  advice  of  the  nurse,  or  still  oftener  of  the  physician,  which  is 
the  cause  of  early  weaning  or  of  failure  to  nurse  at  all.  Many  a  woman 
whose  breast-milk  has  ceased  entirely  for  a  day  or  two,  or  in  whom  it  has 
been  slowly  diminishing,  will  still  be  able  to  nurse  her  baby  if  given  proper 
treatment  and  encouragement.  So,  too,  the  failure  of  the  secretion  to 
appear  in  the  first  few  days  after  parturition  is  no  reason  for  abandoning 
efforts  at  maternal  nursing,  inasmuch  as  it  is  not  at  all  infrequent  to  have 
the  full  secretion  delayed  for  a  number  of  days.  A  scanty  supply  of 
milk  is  no  excuse  for  weaning,  since  even  the  small  amount,  helped  out 
by  artificial  feeding,  is  better  for  the  baby  than  no  breast-milk  at  all. 
So,  too,  the  apparent  fact  that  the  milk  disagrees  with  the  infant  should 
be  regarded  with  suspicion,  especially  in  the  early  weeks  after  birth, 
inasmuch  as  it  often  happens,  when  the  mother  gets  out  of  bed  and  re- 
sumes her  ordinary  method  of  Hfe,  that  both  the  quantity  and  the  quality 
of  the  secretion  will  change  in  a  satisfactory  manner. 

Probably  one  of  the  chief  causes  for  the  early  disappearance  of  the 
secretion  is  the  failure  to  obtain  a  satisfactory  emptying  of  the  breast. 
This  is  especially  liable  to  occur  when  the  infant  is  weakly  and  grows 
easily  fatigued  by  sucking.  Another  cause  often  assigned  for  failure  to 
nurse  is  painful  fissuring  of  the  nipples.  This  is  a  real  difficulty,  but 
generally  can  be  overcome  with  care  and  patience.  Indeed  the  causes 
which  are  assigned  for  the  failure  to  nurse  are  often  of  the  most  trivial 
nature.  This  has  been  interestingly  studied  especially  by  Keller.* 
In  addition  in  the  poorest  classes  is  the  very  real  difficulty  that  nursing 
women  are  often  obliged  to  go  to  work.  This  frequently  necessitates 
early  weaning.  It  is  a  matter  which  can  best  be  dealt  with  from  a  civic 
point  of  view,  aid  being  given  to  mothers  in  these  circumstances. 

Preparation  of  the  Prospective  Mother. — In  view  of  the  impor- 
tance of  breast-feeding  the  preparation  of  the  prospective  mother  for  this 
is  of  great  importance.  The  general  hygiene  has  already  been  briefly 
referred  to  (p.  168) .  The  diet  should  be  rather  more  abundant  than  usual, 
the  bowels  should  be  kept  regular,  gentle  exercise  in  the  fresh  air  should 
be  taken,  and  simple  amusements  enjoyed,  without  much  strain  of  the 
emotions.  Undue  pressure  of  clothing  upon  any  part  of  the  body,  and 
especially  upon  the  breasts,  should  be  avoided  during  pregnancy.  If 
the  nipples  are  retracted  nipple-protectors  may  be  worn.  Useful,  too, 
to  develop  the  nipples  is  gentle  traction  by  the  fingers,  or,,  still  better 
in  some  cases,  by  the  application  of  the  breast-pump  several  times  daily. 

»  Th^se  (Ic  Paris,  1S94.     Rof.  Marfan,  Rev.  mens,  des  mal.  de  I'eiif.,  1894,  XX,  11. 

2  Maneliester  Med.  Cliron.,  1900,  Scries  3,  II,  ;i2;j. 

3  Medical  Kliiiik,  190S,  IV,  2hl. 

*  Wien.  klin.  Wochenschr.,  1909,  XXII,  ();}5. 


84  THE  DISEASES  OF  CHILDREN 

Neither  procedure,  however,  should  be  practised  until  the  last  4 
weeks  of  pregnancy.  At  the  same  time  the  nipples  must  be  hardened 
by  applying  twice  a  day  equal  parts  of  glycerine,  tannic  acid  and  water, 
or  a  saturated  solution  of  boric  acid  in  equal  parts  of  alcohol  and 
water. 

Hygiene  of  the  Nursing  Mother.^ — ^The  care  of  the  nipples  during 
the  period  of  lactation  is  even  more  important  than  before  the  birth  of 
the  child.  After  nursing  thej^  should  at  once  be  washed  and  dried  gently 
and  then  smeared  with  a  little  sweet  oil.  If  they  become  excoriated  or 
fissured,  the  application  of  a  small  amount  of  bismuth-ointment  (equal  parts 
of  bismuth  and  ol.  ricini)  or  of  compound  tincture  of  benzoin  is  often 
efficient.  Sometimes  an  initial  soreness  will  pass  away  entirely  in  a  few 
weeks.  In  other  cases,  where  the  pain  of  nursing  is  intense,  the  use  of 
an  artificial  nipple  must  be  tried.  Great  care  must  be  observed  to  keep 
this  scrupulously  clean. 

During  the  first  few  days  after  childbirth  the  nursing  mother  should 
eat  rather  cautiously,  taking  small  quantities  of  easily  assimilated  food 
frequentty,  lest  overfeeding  produce  indigestion.  There  is  no  need, 
however,  for  any  great  restriction  of  diet.  Toward  the  end  of  the  1st 
week  she  may  have  meat  and  later  may,  as  a  rule,  eat  plentifully  of  any 
nutritious,  digestible  food.  In  addition  to  this  milk,  cocoa,  or  some  other 
light  liquid  nourishment  should  be  taken  at  bed-time  and  possibly  between 
meals.  Weak  tea  and  coffee  are  permissible.  With  regard  to  stimulants, 
the  nursing  mother,  if  in  good  health,  need  nothing  of  the  sort.  Delicate 
mothers  are  sometimes  much  benefited  by  one  of  the  malt  liquors  or  ex- 
tracts, and  the  quality  and  strength  of  the  milk  increased  thereby. 
Alcohol,  however,  is  to  be  prescribed  with  caution  lest  habits  of 
intemperance  be  established. 

A  proper  amount  of  exercise  in  the  open  air,  taken  with  regularity, 
favors  greatly  the  production  of  a  healthy,  nourishing  milk.  Carriage- 
riding  is  beneficial,  but  does  not  take  the  place  of  walking,  begun  as  soon 
after  parturition  as  the  state  of  the  patient  permits.  Late  hours  should 
be  avoided,  and  plenty  of  rest  and  sleep  obtained.  All  causes  of  nervous 
excitement  and  of  worry  should  be  carefully  shunned. 

Rules  for  Nursing. — The  infant  should  be  put  to  the  breast  after 
it  has  been  washed  and  dressed,  and  as  soon  as  the  mother  is  sufficiently 
rested  to  permit  it.  It  lies  upon  its  left  side  to  nurse  from  the  right 
breast,  and  vice  versa,  its  head  being  supported  by  the  arm  of  the  mother 
who  rests  upon  her  side  or  is  propped  up  shghtly  in  bed.  When  the 
mother  is  convalescent  and  able  to  sit  up,  she  should  lean  shghtly  for- 
ward while  nursing,  partly  supporting  and  steacl3dng  the  breast  with 
the  fingers  of  one  hand,  in  order  to  keep  its  weight  from  pressing  against 
the  infant's  nose  and  interfering  with  its  breathing.  If  the  milk  flows 
too  freely  it  may  be  restrained  by  compressing  the  base  of  the  nipple 
slightly  with  the  finger  and  thumb.  One  breast  should  be  sufficient  for 
one  nursing.  The  giving  of  both  breasts  at  a  nursing  is  inadvisable, 
unless  a  scanty  secretion  makes  this  necessary.  A  good  secretion  is 
stimulated  by  a  thorough  emptying  of  the  breast;  and  the  giving  of  both 
of  them  is  liable  to  leave  neither  empty.  An  infant  should  nurse  for  not 
more  than  15  or  20  minutes,  and  should  not  be  allowed  to  go  to  sleep 
until  it  has  finished  its  meal.  Many  infants  are  uniformly  contented 
with  a  shorter  period,  because  they  have  Hursed  with  vigorous  rapidity; 
others  stop  nursing  in  a  few  minutes  because  of  feebleness  or  because  the 
breast  is  empty;  others  from  habit  or  from  an  insufficient  milk-supply 


BREAST-FEEDING  85 

wish  to  nurse  longer.     The  weighing  of  the  infant  before  and  after  nurs- 
ing will  determine  the  actual  condition  present. 

Intervals. — During  the  first  2  days  but  little  secretion  of  any  kind 
is  in  the  breast,  the  needs  of  the  infant  are  slight,  and  it  is  not  necessary 
to  nurse  the  child  oftener  than  from  4  to  6  times  in  the  24  hours.  The 
employment  of  some  substitute  such  as  a  solution  of  sugar  or  a  starchy 
decoction  is  generallj'  entirely  unnecessary,  but  water  should  be  given 
freely.  If  there  is  no  milk  by  the  3d  day  feeding  with  a  very  weak 
substitute-milk-mixture  must  be  commenced  while  efforts  at  nursing 
are  still  continued.  Only  in  exceptional  cases,  where  the  infant  seems 
particularly  hungry,  is  earlier  feeding  required.  As  has  been  pointed  out 
elsewhere  (p.  21)  no  real  benefit  is  gained  by  feeding  an  infant  even  with 
breast-milk  of  another  woman  from  the  1st  day  of  birth.  The  infant 
should  be  kept  very  quiet  after  nursing.  A  little  turning  about,  jogging 
on  the  knee,  or  other  motion  may  very  readily  cause  vomiting.  From 
the  beginning  the  greatest  regularity  should  be  observed  in  the  times 
for  nursing  the  infant,  keeping  in  mind,  too,  the  fact  that  at  night  both 
mother  and  child  should  have  as  much  undisturbed  sleep  as  possible. 
The  duration  of  the  intervals  between  feedings  has  been  a  subject  of 
much  discussion.  The  fact  that  the  healthy,  breast-fed  infant  empties 
its  stomach  often  within  1  hour  after  nursing,  and  practically  always  in 
not  more  than  2  or  2y2  hours  (see  p.  44)  is  an  indication  that  an  interval 
as  long  as  4  hours,  as  recommended  by  many,  may  be  too  great,  and  that 
the  shorter  intervals,  which  have  so  long  been  in  vogue,  should  not  be 
too  readily  abandoned.  The  fact  is  that  there  can  be  no  absolute  rule 
applying  to  all  infants,  although  there  should  be  regular  intervals  for  each 
individual.  In  the  case  of  a  hearty  infant  taking  a  large  amount  of  food 
at  each  nursing  the  intervals  will  necessarily  be  longer.  A  more  delicate 
infant  with  less  appetite,  or  one  with  a  limited  gastric  capacity,  may  need 
more  frequent  feedings.  The  following  statements  can  therefore  apply 
only  in  a  general  way,  being  viewed  as  average  figures  for  average  babies: 
After  the  first  2  days,  in  which  the  child  is  fed  only  every  4  or  6  hours,  the 
interval  between  nursings,  i.e.,  the  heginning  of  each  nursing,  should  be 
from  2  to  23^2  hours  during  the  daytime,  with  only  2  nursings  after  9  or  10 
P.M.  until  morning,  there  being  in  all  from  8  to  10  nursings.  This  holds 
good  for  the  first  4  weeks.  From  4  weeks  to  3  months  the  interval  should 
be  23 ^2  to  3  hours  in  the  daytime,  with  only  1  nursing  after  10  p.m.,  the  total 
number  being  7  or  8.  From  3  months  until  the  age  of  4  or  5  months  the 
interval  should  be  3  to  3^^^  hours  by  day,  perhaps  with  1  nursing  after  10 
o'clock  at  night  in  case  the  child  wakens  for  it.  The  total  number  of 
nursings  is,  therefore,  6  or  7  in  24  hours.  From  this  time  until  the  age 
of  1  year  the  intervals  should  be  3  to  4  hours,  but  no  night  nursing 
after  10  p.m.  is  required,  and  the  total  number  equals  5  or  (3.  The 
following  tabular  arrangement  shows  in  convenient  form  the  intervals 
and  number  of  nursings,  not  including  the  first  two  days  of  life: 

TaBLK    26. FfiEtJT'KNCY   OF    NvRsiNns 

XT        r  f      1-  No.  of  feedings 

.^ge  Intervals,  hours    I     ^?;  S.&'l^^        between  10  p.m. 

in  24  hours  and  6  a.m. 


Birth  to  4  weeks . 
4  weeks  to  3  irbonths . 


2-2)4  8-10 

23^-3     !     7-8 


3  months  to  4  or  5  months 3-3^    I     6-7  1  (?) 

4  or  5  months  to  12  montli.s 3-4     '     5-6     i      0 


86  THE  DISEASES  OF  CHILDREN 

It  may  be  again  emphasized  that  these  figures  are  only  a  guide,  some 
infants  requiring  fewer  and  some  more  frequent  nursings  at  certain  ages. 
The  great  principle  is,  that  a  rule,  once  established,  and  which  has  been 
found  satisfactory,  must  be  followed  with  uniformity,  unless  some  very 
special  reason  arises  for  modifying  it.  The  determining  of  the  exact 
hours  of  the  day  for  the  nursings  will  depend  in  part  on  the  time  the 
infant  regularly  wakens  in  the  morning,  and  in  part  upon  the  hours  of 
its  regular  daytime  naps.  The  child  should  be  awakened  for  its  food 
when  the  appointed  time  comes  during  the  daytime  and  at  the  9  or  10 
P.M.  feeding.  This  will  soon  train  it  to  waken  of  its  own  accord  at  the 
proper  time.  During  the  night  it  may  sleep  as  long  as  it  will,  the  hours 
for  nursing  being  movable  ones. 

Amount  of  Food. — This  can  be  determined  with  even  less  fixity  than 
in  the  case  of  the  intervals,  owing  to  the  very  different  demands  of  dif- 
ferent infants.  It  varies  also  from  time  to  time  in  the  same  infant.  If  an 
unusually  large  amount  is  ingested  at  one  nursing,  the  child  will  naturally 
require  less  at  the  next  one,  or  perhaps  even  refuse  it  altogether.  This 
occurrence  need,  therefore,  be  no  cause  of  alarm  in  the  case  of  a  healthy 
infant.  The  important  consideration  is  that  a  sufficient  total  quantity 
of  breast-milk  be  taken  in  the  24  hours.  Reference  to  the  table  upon 
page  92  will  show  what  may  be  regarded  as  the  average  amount  taken 
at  each  nursing  and  during  the  whole  day.  The  matter  is  referred  to 
again  in  considering  Artificial  Feeding  (p.  133).  It  is  a  point  of  interest, 
as  pointed  out  by  Feer,^  that  in  any  event  the  greater  part  of  the  milk  is 
ingested  by  the  infant  in  the  first  5  minutes  of  nursing. 

Causes  Making  Nursing  Inadvisable  or  Impossible. — Many 
causes  may  render  nursing  impossible  or  harmful.  (See  p.  103.)  Preg- 
nancy is  one  of  the  chief  of  these,  the  milk  becoming  insufficient  or  indiges- 
tible, or  the  secretion  disappearing  entirely.  The  return  of  menstrua- 
tion is  quite  frequently  regarded  by  mothers  as  a  necessary  cause  for 
weaning.  This  is  a  mistake.  The  milk  may  be  temporarily  altered  to  a 
slight  degree,  or  may  exhibit  no  change  whatever.  It  is  true  that  such 
an  occurrence  sometimes  heralds  a  permanent  cessation  of  secretion,  but 
there  is  no  need  by  weaning  to  anticipate  this.  The  development  of  an 
acute  illness  may  render  a  temporary  cessation  necessary,  this  depending 
altogether  on  the  individual  case.  The  effect  upon  the  mother  is  that 
to  be  considered;  and  a  decision  against  nursing  should  not  be  made  too 
hastily.  The  occurrence  of  a  long-continued  illness,  such  as  typhoid 
fever,  generally  prohibits  nursing,  as  the  milk  is  liable  to  be  poor  and  the 
drain  upon  the  strength  of  the  mother  too  great.  The  presence  of  healed 
tuberculosis  is  a  contra-indication,  chiefly  because  the  drain  upon  the 
mother  is  too  severe.  Women  with  active  tuberculosis,  especially  of  the 
lungs,  must  not  nurse,  both  for  their  own  sakes,  and  on  account  of  the 
danger  through  the  close  contact  of  infecting  the  infant.  The  likelihood, 
however,  of  this  infection  occurring  through  the  milk  is  very  slight  indeed. 
Sepsis,  nephritis,  puerperal  eclampsia,  diabetes,  insanity,  and  frequently 
repeated  epileptic  seizures,  are  contra-indications  against  nursing. 
Other  chronic  illnesses  or  the  existence  of  a  delicate  state  of  health  may 
contra-indicate  nursing,  both  because  of  the  harmful  effect  upon  the 
mother,  and  because  the  milk  is  liable  to  be  of  poor  quality.  However 
important  breast-feeding  may  be  for  the  infant,  the  mother's  health 
should  be  the  first  consideration.  One  must  be  sure,  however,  that 
nursing  will  be  undoubtedly  harmful  to  her.     It  is  true  that  the  strain 

1  Jahrb.  f.  Kinderh.,  1896,  XLII,  225. 


BREAST-FEEDING  87 

of  nursing  often  does  cause  loss  of  weight  and  of  strength  in  an  anemic 
or  neurotic  mother;  but  it  is  generally  a  condition  which  can  be  tolerated 
without  any  permanent  harm,  certainly  for  a  time  at  least,  and  the  effort 
at  nursing  ought  to  be  made.  Syphilis  existing  in  the  mother  is  no  contra- 
indication to  her  nursing,  since  the  child  is  also  certainly  syphilitic  at 
the  time  of  its  birth.  So,  too,  an  infant  with  congenital  syphilis  may 
continue  to  nurse  without  danger  to  the  mother,  since  she  must  be 
syphilitic  also.  ^Mastitis  prohibits  nursing  from  the  diseased  breast  as 
long  as  the  suppuration  continues.  Retraction  of  the  nipple  which  cannot 
be  overcome,  and  fissures  which  will  not  heal,  causing  unbearable  pain, 
often  make  the  continuance  of  nursing  impossible.  Sometimes  an 
artificial  nipple  will  overcome  the  difficulty,  and  in  any  case  thorough  trial 
of  nursing  should  be  made  before  this  is  abandoned.  The  secretion  of 
milk  on  which  the  infant  persistently  does  not  thrive  makes  weaning 
imperative.  There  exists,  however,  a  far  too  great  readiness  on  the  part 
of  physicians  to  advise  weaning  under  these  circumstances,  without 
sufficienth^  long-continued  efforts  to  remove  the  difficulty. 

On  the  part  of  the  infant  nursing  may  be  temporarily  or  permanently 
interfered  with  by  severe  coryza,  cleft  palate,  or  conditions  of  great 
debihty.  The  last  is  seen  especially  in  premature  infants,  or  those  with 
congenital  asthenia  from  other  causes,  the  baby  being  too  weak  to  suck 
properly.  In  this  event  the  breast-milk  must  be  fed  from  a  dropper 
until  the  child  is  stronger. 

Signs  that  Breast=feeding  is  not  Satisfactory. — The  breast- 
milk  may  be  insufficient  in  quantity;  the  child  may  for  various  reasons 
fail  to  get  enough  of  what  is  in  the  breast;  or  the  milk  may  be  inferior  in 
quality.  Not  every  breast-milk  is  suitable  for  the  infant  even  when  suffi- 
ciently abundant.  It  is  important  to  determine  as  promptly  as  possible 
whether  nursing  is  satisfactory,  as  otherwise  valuable  time  may  be  lost 
and  damage  done.  The  normal  infant  shows  a  steady  gain  in  weight 
according  to  the  rates  already  given  (p.  23) .  This  does  not  mean,  however, 
that  the  gain  must  be  regular  and  unbroken  from  day  to  day,  for  such  is 
by  no  means  the  rule;  nor  does  it  indicate  that  a  gain  which  is  not  quite 
up  to  the  normal  figures  necessitates  a  change  in  the  diet.  A  baby 
who  is  receiving  a  supply  of  milk  defective  in  qualit}^  or  quantity  con- 
stantly falls  behind  in  its  weight-curve  and  in  its  appearance  of  well- 
being;  is  liable  to  become  hungry  too  soon;  to  cry  with  dissatisfaction 
when  or  before  nursing  is  over;  often  has  too  few  bowel-movements  in 
the  twenty-four  hours,  and  these  are  frequently  constipated.  Weighing 
the  baby  or  the  mother  before  and  after  each  nursing  will  show  whether 
the  absolute  daily  quantity  of  milk  ingested  is  insufficient  (p.  92). 
Sometimes  a  weight-curve  which  has  been  entirely  satisfactory  perhaps 
for  some  months  makes  a  decided  deviation  from  the  normal  during  1  or 
2  weeks,  yet  without  there  being  any  other  noticeable  disturbance  in 
the  condition  of  the  child.  This  is  very  liable  to  mean  that  the  maternal 
secretion  is  unsatisfactory.  In  other  cases  it  is  evident  that  the  milk 
produces  symptoms  of  indigestion.  Actual  vomiting  should  not  occur 
in  the  normal  infant,  unless  as  a  result  of  its  being  disturbed  in  some  way. 
It  may  not  infrequently  be  on  account  of  indigestion  having  developed, 
either  from  the  milk  being  too  abundant  or  too  rich  in  some  respect. 
For  the  same  reason  the  stools  may  be  too  frequent  or  not  well  digested: 
and  the  occurrence  of  colic  is  a  very  common  evidence  of  indigestion.  If 
with  these  symptoms  the  baby  is  still  thriving  normally  in  other  respects, 
there  can  be  no  thought  of  weaning,  although  an  effort  at  a  modification 


88  THE  DISEASES  OF  CHILDREN 

of  the  secretion  (p.  106),  or  of  some  of  the  details  of  the  method  of  feeding 
should  be  made,  and  treatment  for  the  indigestion  given.  Again,  a 
child  maj^  fail  to  gain  on  account  of  the  existence  of  some  disease  other 
than  a  digestive  one,  and  a  careful  study  of  the  case  must  be  made  for 
some  concealed  ailment  before  concluding  that  the  breast-milk  is  unsatis- 
factory. The  special  symptoms  produced  by  an  excess  of  the  different 
elements  of  the  food  are  referred  to  more  conveniently  under  Artificial 
Feeding  (p.  127). 

MIXED  FEEDING 

Very  many  women  secrete  only  enough  milk  to  nourish  the  child  in 
part.  Such  circumstances  render  it  necessary  either  to  wean,  to  employ 
a  wet-nurse,  or  to  supplement  with  artificial  food.  The  last  plan  is 
greatly  to  be  preferred  to  complete  weaning,  provided  the  mother's  health 
is  not  suffering  and  her  milk  is  of  good  quality.  To  determine  the  latter 
the  milk  should  be  analyzed  and  then,  if  necessary,  an  attempt  be  made 
to  improve  its  quantity  or  quality.  If  efforts  to  improve  it  fail,  substitute 
feedings  should  be  commenced,  at  first  a  little  weaker  than  normal  human 
milk  and  then,  when  tolerance  of  the  new  food  is  established,  of  such 
percentage-strength  as  the  gam  in  weight  shows  to  be  requisite.  So,  too, 
even  though  the  mother's  milk  may  be  sufficient,  partial  substitute 
feeding  maj^  well  be  commenced  if  her  health  is  distinctly  suffering. 
The  number  of  substitute  feedings,  and  the  time  in  the  twenty-four  hours 
for  them,  depend  always  on  individual  circumstances.  They  may  either 
replace  entirely  some  of  the  feedings,  the  mother  nursing  at  other  times 
from  both  breasts  if  necessary ,  or  a  small  bottle  may  be  given  after  each 
nursing.  The  latter  is  in  many  respects  the  better  plan,  so  far  as  the 
baby  is  concerned,  since  the  more  frequent  stimulation  of  the  breast  by 
nursing  tends  to  maintain  the  supply  of  milk.  In  fact,  the  giving  of  two 
or  more  bottles  daily  without  nursing  immediately  preceding  it  is  ex- 
tremely liable  to  hasten  an  entire  disappearance  of  the  maternal  secretion. 
From  the  side  of  the  mother,  however,  the  giving  of  one  or  two  bottles 
daily  without  nursing  has  the  advantage  that  it  furnishes  her  with  an 
increased  degree  of  freedom.  Systematic  weighing,  at  least  twice  a  week, 
will  be  the  indication  of  the  success  of  the  mother  and  of  any  necessity 
to  wean  entirely  and  quickly.  As  to  the  amount  to  be  given  at  each 
feeding,  this  depends  upon  the  age  of  the  child,  and  the  quantity  it 
obtains  from  the  breast.  To  determine  this  the  baby  may  be  weighed 
before  and  after  each  nursing  during  one  or  two  days,  and  then  given 
enough  artificial  food  to  make  up  the  total  quantity  which  the  age  would 
naturally  require  in  the  average  infant.     (See  p.  133.) 

It  is  frequently  advised  to  give  a  baby  one  bottle  of  artificial  food 
from  the  beginning,  in  order  that  it  may  become  accustomed  to  this  in 
case  of  the  maternal  supply  faihng.  This  seems  hke  meeting  a  possible 
danger  by  undergoing  a  real  one;  and  it  is  not  necessary  if  the  infant  is 
early  trained  to  take  water  from  a  bottle.  The  only  advantage  is  the 
freedom  for  the  mother  already  mentioned.  It  is  of  common  occurrence 
in  attempting  to  employ  mixed  feeding  to  find  that  the  infant  soon  will 
refuse  the  breast  and  take  only  the  bottle,  finding  nursing  from  it  easier. 
Judicious  starving  will  generally  overcome  the  difficulty.  Sometimes 
putting  a  little  sugar  or  some  of  the  bottle-food  on  the  maternal  nipple, 
or  the  employment  of  an  artificial  rubber-nipple,  will  persuade  the  infant 
to  nurse. 

It  does  not  necessarily  follow  that  mixed  feeding,  once  commenced, 


WEANING  89 

shall  continue  indefinitely.  The  mother  may  be  suffering  from  a  tempo- 
rary impairment  of  health,  or  the  milk  may  have  diminished  as  a  result 
of  maternal  anxiety  or  other  psj'chic  cause;  or  the  difficulty  may  exist 
only  in  the  first  few  weeks  of  the  infant's  life.  It  will  then  be  found, 
with  the  increasing  supply  of  milk,  that  the  infant  has  no  desire  for  the 
bottle  and  is  yet  gaining  weight  normally,  and  a  purely  maternal  nursing 
is  thus  reinstated.  During  the  period  of  mixed  feeding,  however,  it  is 
very  important  to  see  that  the  mother's  breasts  are  frequently  emptied 
as  thoroughly  as  possible  in  order  to  stimulate  the  secretion, 

WEANING 

With  very  many  women  the  supply  of  milk  is  liable  to  diminish  greatly 
by  the  time  the  infant  is  8  or  9  months  old,  or  even,  as  previously 
stated,  before  this.  Weaning  is  thus  rendered  necessary  early.  When, 
however,  nothing  of  this  sort  occurs,  the  child  should  be  fed  on  the 
breast  alone  during  the  first  10  or  12  months  of  life.  We  should  certainly 
attempt  to  have  maternal  nursing  continue  until  the  infant  is  5  or  6  months 
of  age,  after  which  period  substitute  feeding  will  be  better  tolerated. 
Nursing  longer  than  12  months  generally  offers  no  possible  benefit  and 
is  often  deleterious  to  the  infant.  It  is  not  infrequently  practised  by 
mothers  in  the  hope  of  preventing  conception. 

Weaning  should  not  be  done  in  hot  weather  if  it  can  be  avoided.  At 
this  season,  if  the  child  is  clearly  thriving  on  the  breast-milk  and  the 
mother  is  not  suffering,  it  is  well  to  prolong  breast-feeding  beyond  the 
usual  time  for  weaning  and  until  the  hot  weather  is  over.  Exceptionally 
the  reverse  is  true,  and  weaning  may  well  be  hastened  before  hot  weather 
sets  in.  This  is,  however,  not  often  required,  and  the  step  must  be  taken 
cautiously.  With  proper  guarding  against  the  employment  of  an  im- 
pure milk,  a  baby  may  readily  be  weaned  in  the  summer-time  if  necessity 
arises. 

Some  of  the  causes  which  make  weaning  necessary  have  already  been 
discussed  (p.  86).  The  sudden  cessation  of  the  maternal  supply,  the 
secretion  of  milk  which  is  harmful  to  the  child,  or  decided  illness  on  the 
part  of  the  mother,  may  compel  a  sudden  complete  weaning.  So,  too, 
the  absolute  refusal  of  the  child  to  take  anything  but  the  breast  may  re- 
quire it.  This  last  is  a  very  real  and  not  infrequent  factor  in  cases  where 
the  mother's  milk  is  not  entirely  sufficient.  It  is  sometimes  necessary 
to  withdraw  the  breast  absolutely  and  almost  to  starve  the  child  for  sev- 
eral days  before  it  will  take  its  artificial  nourishment.  This  can  often 
be  avoided  by  teaching  the  breast-fed  child,  early  in  life,  to  suck  water 
from  a  bottle.  When,  however,  such  an  emergency  arises,  the  bottle 
should  be  offered  to  the  child  in  the  mother's  absence,  as  the  infant  is 
more  prone  to  be  content  with  it  under  these  circumstances. 

Whenever  possible,  however,  weaning  should  be  done  gradually. 
The  child  should  Ije  started  at  the  age  of  10  or  1 1  months  with  the  mixed 
feeding  described.  At  first  only  one  bottle  is  given  daily,  using  a  for- 
mula much  weaker  than  the  needs  actually  demand,  and  gradually 
increasing  the  strength  of  the  milk  until  one  sufficiently  nourishing  is 
found  to  be  well  tolerated.  In  a  few  days  another  breast-feeding  siiould 
be  omitted  and  two  feedings  of  inilk-mixtiuc  given.  This  process  is  con- 
tinued until  the  infant  is  entirelj'onartifici  ilfood.  After  this  the  strength 
and  quaUty  of  the  food  is  to  be  increased  gradually  in  the  manner  to  be 
considered  later  (p.  132). 


90  THE  DISEASES  OF  CHILDREN 

FEEDING  BY  A  WET-NURSE 

Advantages.^ — ^The  milk  of  a  wet-nurse  is  beyond  question  generally 
the  best  substitute  for  mother's  milk.  In  fact  in  many  cases  it  may  be 
better  than  the  milk  of  the  mother.  Many  infants  have  been  saved  by 
wet-nursing  who  would  unquestionably  have  perished  if  artificial  feeding 
had  been  continued.  This  is  particularly  true  of  marantic  infants  with 
serious  digestive  disturbances.  So,  too,  the  rearing  of  young  infants, 
normal  at  the  start,  with  artificial  food  in  the  heat  of  summer,  and  es- 
pecially in  the  cities,  is  often  of  such  difficulty  that  wet-nursing  is  greatly 
to  be  desired,  and  this  should  certainly  be  urged  by  the  physician,  if 
a  brief  trial  with  artificial  food  shows  any  deterioration  of  health. 

Yet,  on  the  other  hand,  it  is  a  mistake  to  regard  wet-nursing  as  an 
unqualified  good.  Very  many  wet-nurses  are  prone  to  take  advantage 
of  their  important  position,  become  overbearing  and  insolent,  and  be  a 
trial  in  the  household  which  words  cannot  describe.  The  nurse  often 
turns  out  unreliable  and  may  abandon  her  position  at  some  most  inop- 
portune time.  It  does  not  follow,  too,  that  the  milk  of  the  wet-nurse 
will  agree  with  her  foster-child.  Sometimes  milk,  at  first  abundant  and 
good,  becomes  altered  by  the  changed  methods  of  living  which  the  nurse 
experiences  in  her  new  position  or  by  anxiety  or  nervousness,  although 
this  may  be  only  a  temporary  matter.  For  all  these  reasons  mothers 
dislike  the  introduction  of  a  wet-nurse  into  the  household.  Very  many  of 
them,  too,  have  so  strong  a  prejudice  against  having  their  babies  nursed 
b}'  another  woman,  that  they  prefer  seeing  them  die  rather  than  con- 
sent to  it,  and  I  have  heard  them  frankly  admit  this.  Others  draw 
the  line  at  the  engaging  of  a  woman  other  than  white.  All  this  is  natu- 
rally wrong  and  distinctly  selfish,  since  the  baby's  good  should  be  the 
first  consideration.  Equally  wrong,  and  often  fatal  in  its  results,  is  the 
deferring  of  the  employment  of  a  wet-nurse  until  it  becomes  a  last  resort. 

It  is  sometimes  urged  that  the  employment  of  a  wet-nurse  is  inhuman 
and  selfish  on  the  part  of  the  employer,  because  it  forces  the  nurse  to 
deprive  her  own  infant  for  the  sake  of  the  foster-child.  This  is  altruistic 
in  theory,  but  illogical  in  fact.  The  wet-nurse's  own  child  is  probably 
in  a  healthy  and  flourishing  condition,  or  the  woman  would  not  have  been 
selected  as  a  nurse.  The  foster-baby  is  probably  having  dangerous 
digestive  trouble  existing  or  threatening,  or  a  wet-nurse  would  not  have 
been  sought.  By  employing  a  wet-nurse  there  is  much  greater  chance 
of  saving  two  lives  instead  of  one.  Still  more  important  is  the  fact  that 
the  wet-nurse  takes  this  position  to  obtain  the  livelihood  of  herself 
and  child.  If  she  did  not  do  this,  she  would  be  obliged  to  take  up  some 
other  and  less  well-paid  work,  and  in  this  event  she  could  not  nurse 
her  baby. 

The  Wet=nurse's  Baby.- — There  is  no  objection  to  the  wet-nurse 
taking  her  own  baby  with  her  into  her  new  position.  In  fact,  she  is  less 
liable  to  be  anxious  about  it,  and  this  conduces  to  the  maintenance  of 
her  supply  of  milk.  On  the  other  hand,  it  is  bad  policy,  in  my  experience, 
to  make  any  arrangement  whereby  she  shall  try  to  supply  milk  for  both 
babies.  The  foster-baby  is  the  one  hkely  to  suffer  in  this  event.  Indeed, 
the  only  vital  objection  against  the  presence  of  the  nurse's  baby  in  the 
house  is  the  difficulty  in  preventing  the  nurse  from  a  surreptitious  de- 
frauding of  the  needy  foster-child.  Unless  such  a  procedure  can  be  abso- 
lutely controlled  it  is  better  that  the  nurse  leave  her  own  baby  behind. 
There  are  instances,  however,  when  the  opportunity  for  nursing  both  chil- 


FEEDING  BY  A  WET-NURSE  91 

dren  is  an  advantage.  This  is  especially  true  when  the  supply  of  milk 
is  very  abundant,  since  the  foster-baby  may  be  overfed,  or  if  too  weakty 
to  empty  the  breast  properly  the  secretion  is  not  maintained  and  may  dry 
up.  The  employment  of  a  breast-pump,  or  expression  of  the  milk,  is 
by  no  means  as  satisfactory  for  this  emptying  as  is  the  direct  sucking 
by  an  infant.  Whether  or  not  the  wet-nurse's  child  accompany  her, 
it  is  only  humane  that  the  employer  see  to  it  that  the  infant  is  well  cared 
for. 

Selection  of  a  Wet=nurse. — The  wet-nurse  selected  should  be 
strong,  between  20  and  30  years  of  age,  of  quiet  disposition,  and  not  nerv- 
ous. Other  things  being  equal,  her  general  health  should  be  good, 
although  delicate  looking  wet-nurses  not  infrequently  supply  excellent 
milk.  Particularly  she  should  be  not  anemic,  not  too  fat,  and  free  from 
any  evidence  of  syphilis  or  tuberculosis,  or  of  parasitic  or  infectious  dis- 
ease of  the  skin.  The  presence  of  a  positive  von  Pirquet  reaction  is, 
of  itself,  not  a  contra-indication  to  her  employment.  The  existence  of 
apparent  health  in  the  mother,  and  especially  in  her  own  child  makes 
it  probable  that  syphilis  is  absent;  but  whenever  possible  a  Wassermann 
test  should  be  made.  Conversely  it  may  be  said  that  a  syphilitic  foster- 
baby  should  not  nurse  from  a  healthy  wet-nurse.  The  nipples  must  be 
prominent  enough  to  be  grasped  easily  by  the  child,  and  be  free  from 
fissures.  The  mammae  should  be  firm  and  hard  before  nursing,  and  should 
become  flabby  to  some  extent  when  emptied.  If  they  do  not,  their  size 
and  shape  before  nursing  probably  depend  on  the  fact  that  they  contain 
more  fat  than  glandular  tissue.  The  best  test,  however,  of  the  amount  of 
secretion  is  the  weighing  of  the  infant  before  and  after  nursing,  since  the 
appearance  of  the  breast  is  so  often  deceptive.  The  weighing  should  be 
done  after  each  nursing  for  a  day  or  more.  A  single  weighing  is  not  satis- 
factory. In  connection  with  the  weighing  it  may  be  said  that  this  is  a 
check,  too,  upon  a  young  infant  recefving  far  more  milk  than  it  can  prop- 
erly digest.     (See  Quantity  of  Milk,  p.  92.) 

The  nurse's  baby  should  by  preference  be  some  weeks  old  in  order  to 
show  that  the  milk  has  been  nutritious,  and  that  a  condition  of  equilib- 
rium may  have  been  reached.  If  her  child  is  healthy  and  well  nourished 
it  is  an  indication  that  the  milk  will  probably  agree  with  the  foster- 
child.  There  is  no  necessity  of  having  the  nurse's  own  child  and  her 
foster-child  of  very  nearly  the  same  age,  inasmuch  as  there  is  compara- 
tively little  change  in  a  woman's  milk  after  the  1st  month.  (See  p.  103.) 
Yet,  on  the  other  hand,  the  difference  should  not  be  too  great,  especially 
if  her  own  child  is  much  older,  lest  the  quality  deteriorate  or  the  secre- 
tion cease  before  the  younger  foster-child  is  of  the  age  to  wean. 

When  practicable  the  nurse's  milk  should  be  analyzed  before  she  is 
employed.  Should  her  milk  not  seem  sufficiently  abundant  during  the 
first  days  after  she  is  engaged,  one  nmst  not  at  once  despair  of  her,  for 
the  scantiness  may  be  remediable  by  hygienic  treatment,  or  may  be  the 
result  merely  of  nervous  impressions  such  as  excitement  from  assuming 
the  new  position,  worry  at  weaning  her  child,  and  the  like. 

The  moral  character  of  the  wet-nurse  has  no  effect  whatever  upon  the 
child;  that  is  to  say,  traits  of  character  are  not  transmitted  with  the  food. 
It  is  similarly  a  matter  of  indifference  whether  her  color  is  white  or  black. 
Yet  her  character  cannot  be  entirely  disregarded  for  other  reasons.  If 
she  is  intemperate,  vicious,  and  irresponsible,  an  infant  cannot  be 
safely  entrusted  to  her  charge,  however  normal  her  milk-secretion  may  be. 
A  wet-nurse  who  is  a  primipara  should  certainlj'  not  be  rejected  l)ecause 


92 


THE  DISEASES  OF  CHILDREN 


she  is  unmarried.     If  she  has  had  more  than  one  illegitimate  child  she 
is  probably  depraved  in  other  respects  and  should  not  be  trusted. 

Hygiene  of  the  Wet=nurse. — The  rules  for  the  diet  and  hygiene 
of  the  wet-nurse  'are  those  already  given  for  the  nursing  mother  (p.  84). 
Yet  it  is  important  to  remember  that  the  diet  of  the  household  is  probably 
not  that  to  which  the  nurse  has  been  accustomed,  and  that  no  sudden 
change  to  a  richer  and  more  delicate  diet  should  be  made,  lest  some 
alteration  in  the  character  or  quantity  of  the  milk  due  to  indigestion 
or  other  causes  result.  It  is  important,  too,  that  a  woman  who  has  fol- 
lowed an  active  working  life,  be  not  forced  to  sit  about  and  do  nothing. 
Such  a  course  is  sure  to  affect  her  milk.  She  should  as  far  as  possible 
do  the  kind  of  work,  eat  the  sort  of  food,  and  in  general  live  the  life  to 
which  she  has  been  accustomed. 


HUMAN  MILK 

Quantity. — The  quantity  secreted  depends  largely  upon  the  demands 
made  by  the  infant.  Consequently  there  is  less  milk  supplied  in  the  early 
period  of  infancy  than  later.  The  estimation  of  the  average  secretion 
can  therefore  be  only  approximate.  Systematic  studies  extending  over 
some  months,  made  by  weighing  infants  before  and  after  each  nursing, 
have  been  carried  on  by  very  few  investigators.  Feer^  has  combined 
a  number  previously  published  with  experiments  of  his  own.  The 
following  figures  deduced  from  his  table  represent  the  average  total 
daily  amounts  taken  by  the  infants  studied,  as  well  as  the  average  at 
each  nursing  during  the  1st  half  year: 

Table  27. — Secretion  of  Breast  Milk 


Age 

Average  amount  taken  daily 

Average  amount  at  each  nursing  ' 

Grams 

Fluidounces 

Grams 

Fluidounces 

1st  week 

310 

558 

601 

666 
725-818 
800-832 
847-879 
842-922 

10.5 

18.9 

20.3 

22.5 
24:5-27.6 
27.0-28.1 
-28.6-29.7 
28.5-31.2 

66 

90 

97 
111 
125-141 
138-146 
154-157 
153-174 

2.2 

2d  week 

3.0 

3d  week 

3.3 

4th  week 

3.7 

5  to  8  weeks 

9  to  12  weeks 

13  to  16  weeks 

17  to  20  weeks 

4.2-4.8 
4.7-4.9 
5.2-5.3 
5.2-5.9 

During  the  first  2  days  of  the  1st  week  the  amount  taken  by  the  child 
is  necessarily  much  less  than  later,  only  10  to  20  c.c.  (0.34  to  0.68  fi.oz.), 
since  secretion  has  not  been  fully  established.  The  figures  obtained  by 
Selter^  in  3  systematically  studied  cases  are  somewhat  lower  than  those 
of  Feer.  All  estimates  made  in  this  way,  however,  show  only  the  amount 
of  milk  taken  by  the  child,  and  not  that  which  the  breast  is  capable  of 
secreting.  An  average  breast  should  give  an  average  secretion  of  1200 
grams  (40. G  fl.oz.)  a  day  during  the  nursing  period  (Schlossmann).^  A 
wet-nurse  feeding  several  infants  may  not  infrequently  secrete  daily  in 
the  neighborhood  of  2  litres  (67.6  fl.oz.),  or  occasionally  even  3  litres 

1  Jahrb.  f.  Kinderh.,  1896,'  XLII,  195;  1902,  LVI,  421. 
^Archiv  f.  Kiriderheilk.,  1903,  XXXVII,  91. 
3  Arch.  f.  lunderh.,  1902,  XXXIII,  194. 


HUMAN  MILK  93 

(101.4  fl.oz.).  Laurentius^  observed  an  instance  where  3450  grams 
(116.66  fl.oz.)  were  produced  in  a  single  day;  and  Rommel-  the  secretion 
of  4125  grams  (139.48  fl.oz.)  in  one  day.^ 

Colostrum. — The  secretion  occurring  during  the  first  3  or  4  days 
after  the  birth  of  the  child,  and  to  some  extent  before  its  birth,  is  called 
"colostrum."  It  differs  from  milk  not  only  to  some  degree  in  chemical 
composition,  but  in  the  presence  of  the  "colostrum  corpuscles."  These 
are  cells,  probably,  as  Czerny*  believes,  of  lymphoid  nature  or  are  derived 
in  part  from  the  "mast"  cells  (linger).^  They  are  4  or  5  times  larger 
than  the  average  leucocyte,  are  phagocytic,  contain  a  nucleus,  are  filled 
with  fat-globules,  and  are  at  first  very  numerous  (Fig.  16) .  They  persist 
in  constantly  decreasing  numbers  until  the  end  of  the  2d  week.  A  longer 
continuation  indicates  that  the  milk  is  not  in  a  healthy  state.     The 


Fig.   16. — Milk  axd  Colostrum. 
Upper  half  human  milk;  lower  colostrum.     Magnified.     {Thiemich,  Peer's  Lehrbuch  der 
Klndcrhcilkunde,  1914,  6.) 

corpuscles  reappear  also  when  nursing  is  intermitted  for  a  day  or  two, 
or  when  the  breasts  are  not  sufficiently  emptied.  Any  breast-milk  in 
which  colostrum-corpuscles  are  present  in  decided  numbers  is  liable  to 
disagree  with  the  infant.  In  addition  to  the  corpuscles  and  fat-globules, 
mononuclear  and  polymorphonuclear  leucocytes  may  be  found.  The 
fat-globules  of  colostrum  are  very  unequal  in  size. 

Alost  investigators  agree  that  the  colostrum  of  the  first  few  days  before 
milk  begins  to  be  secreted  is  richer  in  protein  and  salts  and  poorer  in 
sugar  and  fat  than  the  fully  developed  milk.  The  results  from  analyses 
made  by  different  investigators  is  shown  in  the  following  table: 

»  Arch.  f.  KindfM-h..  1912,  LVI.  275. 

2  Miinch.  mod.  Wochonsfhr.,  190.5,  LII,  444. 

^  The  calculations  of  the  Kiifz;lish  nioasuro  as  fjivon  above  are  on  the  assumption 
that  Kranis  were  taken  as  the  equivalent  of  cul)ic  centimeters.  If  the  milk  was 
weighed,  the  volume  secreted  will  i)e  slightly  less  than  the  figures  given. 

•■  Henoch's  Festsclirift.  1X90,  194. 

'  Virchow's  Archiv.,  1895,  XLI,  159. 


94 


THE  DISEASES  OF  CHILDREN 


Table  28. — Composition  of  Colostrum 


.\driancei 

i 

Woodward- 

Soldner' 

Konig* 

Fat 

3.46 
2.05 
6.35 
0.23 
12.10 
87.89 

4.00 

1.90 

6.50 

0.20 

12.50 

87.50 

3.26 
1.79 
5.83 
0.30 
12.09 
87.91 

3  34 

Protein  

3  07 

Lactose 

Ash 

Total  solids 

Water 

5.27 

0.40 

12.08 

86.70 

The  difference  in  these  figures  depends  largely  upon  the  material  analyzed. 
The  analj'^sis  of  Konig  is  of  the  colostrum  of  the  first  3  days;  the  others  of 
that  of  the  first  5  or  6  days  or  longer. 

The  color  of  colostrum  is  deep  lemon-yellow  due  to  the  presence  of 
the  corpuscles,  the  reaction  decidedly  alkaline,  and  the  specific  gravity 
1040  to  1060.  It  is  coagulated  firmly  by  heat  and  by  acids.  The 
excess  of  protein  and  of  salts  is  probably  the  cause  of  the  sHghtly  laxative 
action  which  colostrum  is  believed  to  possess.  The  fat  of  colostrum  is 
richer  in  oleic  acid  than  is  that  of  human  milk  (Engel)  f  and  according  to 
Bauer^  the  protein  is  of  the  nature  of  a  direct  transudate,  in  contra- 
distinction to  that  of  fully  developed  milk,  and  is  analogous  to  that  found 
in  blood-serum.  The  mineral  matter  differs  from  that  of  milk  in  that 
magnesium  and  phosphorus  are  in  relatively  greater  amounts  and  possibly 
the  calcium  also,  while  the  proportion  of  sodium  is  smaller. 

The  chemical  characteristics  of  colostrum  persist  to  some  extent, 
although  in  a  constantly  diminishing  degree,  during  the  first  2  weeks  after 
childbirth,  by  which  time  the  "colostrum  period"  may  be  said  normally 
to  have  closed,  and  the  "equilibrium  milk"  or  "mature  milk"  is  secreted. 

Composition  of  Human  Milk. — Human  milk,  like  that  of  other 
animals,  is  an  emulsion  consisting  chiefly  of  water,  containing  suspended 
or  dissolved  in  it  certain  amounts  of  fat,  sugar,  protein  and  salts.  It  is 
the  product  of  actual  secretion  of  the  breast,  the  epithelial  cells  not 
undergoing  destruction  in  the  process  of  its  formation.  It.is  not  a  transu- 
date, although  to  a  limited  extent  substances,  such  as  certain  drugs, 
may  simply  pass  through  the  gland  and  be  excreted  in  the  milk.  It 
begins  to  be  secreted  by  about  the  3d  day  after  birth,  or  sometimes  later, 
the  characteristics  of  colostrum  being  still  present  to  some  extent.  It  is 
of  a  bluish-white  color  and  has  a  slightly  sweetish  taste  and  an  amphoteric 
or  faintly  alkaline  reaction  with  litmus  paper.  Kerley,  Gieschen  and 
Myers^  have  shown  that  with  phenolphthalein  it  is  always  faintly  acid. 
The  white  color  is  not  due  solely  to  the  existence  of  fat  in  emulsion,  but 
probably  also  to  the  presence  of  casein  and  calcium  phosphate,  since  it  is 
to  be  seen  as  well  in  fat-free  milk.  The  specific  gravity  averages  about 
1030  to  1031  with  a  normal  range  of  1028  to  1034.  Greater  variations 
occur,  and  Konig*  gives  a  range  of  1020  to  1036.  Coagulation  is  caused 
by  acid,  but  only  to  a  slight  degree  as  compared  with  cow's  milk;  and 

1  Arch,  of  Ped.,  1897,  XIV,  22. 

2  .Journ.  Exper.  Med.,  1897,  March. 

3  Zeit.  f.  Biol.,  1898,  XXXVI,  280. 
*  Chemie  des  menschl.  Nahrungsmitiel,  1903,  I,  100. 
6  Sommerfeld's   Handb.    der   Milchkunde,    1909,  810. 

Diseases  of  Nutrition  and  Infant  Feeding,  1915,  96. 
6  D3  It.    med.  Wochenschr.,  1909,  XXXV,  1657. 
'  New  York  Med.  Rec,  1903,  Aug.  8. 
^Loc.  ciL,  110. 


Ref.    Morse  and  Talbot, 


HUMAN  MILK 


95 


that  by  rennet  does  not  take  place  except  in  the  presence  of  acid,  and  then 
less  firmly  than  in  the  case  of  cow's  milk.  The  casein  is  changed  to 
paracasein  under  the  influence  of  rennet.  Under  the  microscope  are 
found  crowded  oil-globules  varying  in  size  (Fig.  16).  In  addition  to 
these  are  a  limited  number  of  leucocytes,  and  a  very  large  number  of 
extremely  minute  ultramicroscopic  particles  consisting  of  casein  (Alex- 
ander and  Bullowa).^ 

Numerous  and  careful  analyses  of  the  composition  of  milk  have  been 
made.  There  is  necessarily  a  considerable  variation  among  individual 
women  and  those  of  different  races  and  conditions  of  life,  and  even  of  the 
same  woman  at  different  times  of  the  day.  The  following  table,  after 
Czerny  and  Keller, ^  shows  some  of  the  variations  according  to  the  analy- 

Table  29 


Investigators 


Fat, 
per  cent. 


Sugar, 
per  cent. 


Protein, 
per  cent. 


Ash, 
per  cent. 


SoUds, 
per  cent. 


Pfeiffer^ I  0.76-9.05 

Johannessen   and 

Wang^ 2.   7-4.6 

V.  and  J.  S.  Adriance^  1.31-7.61 

Guirandfi 1.75-6.18 

Camerer   and    Sold- 

ner^ 1.27-5.77 

Schlossmann* 1.65-9.46 


4.22-7.65    1.049-3.04 


5.  9-7.8 
5.35-7.95 

6.  7-7.7 

5.35-7.52 
5.2-10.90 


0.   9-1.3 

0.23-2.60 

0.85-1.4 

0.83-1.87 
0.56-3.4 


0.104-0.446 


0.09-0.28 
0.    1-0.27 


8.23-15.56 


9.19-15.31 
11.   2-16.3 


0.11-0.36      9.41-14.11 


ses  of  different  investigators: 

For  an  approximate  analysis  of  average  human  milk  the  following  may 
be  assumed  as  a  working  guide: 

Table  30. — Average  Composition  of  Human  Milk 

Fat 3.5-4.0  per  cent. 

Sugar 6.5-7.0  per  cent. 

Protein 0.1-  1.5  per  cent. 

Ash 0.2  per  cent. 

Water 87.0-88.0  per  cent. 

Total  solids 12.0-13.0  per  cent. 

There  are  also  present  in  small  amounts  certain  nitrogenous  substances 
not  of  the  protein  class;  citric  acid;  and  a  number  of  other  bodies  little 
understood. 


THE  DIFFERENT  CONSTITUENTS  OF  MILK  AND  THEIR  NORMAL 

VARIATIONS 

Fat. — The  fat  in  milk  is  in  the  form  of  many  globules  of  size  varying 
from  0.0033  to  0.01  mm.  (0.00013  to  0.00039  inches)  in  diameter,  and  in 
number  averaging  1,026,000  to  the  c.mm  (Bouchut).^  These  form  an 
emulsion  with  the  milk-plasma.     It  is  disputed  whether  the  globules  are 

1  Journ.  Anier.  Med.  As.soc.,  1910,  LV,  1196. 

^  Des  Kindes  Erniihrung,  Erniihrungstorungen  und  Erniihrungstherapie,  1906,  I, 


416 


'  Verhandl.  XI,  Ver.sainml.  d.  Gesellsch.  f.  Kinderh.,  1894,  131. 

*  Zeit.  f.  physiol.  Chem.,  1898,  XXIV,  499. 

«  Arch,  of  Pod.,  1897,  XIV,  27. 

«  Th(^se  de  Hordoaux,  1897. 

'  Zeit.  f.  Biol.,  1S9S,  XXXVI,  280. 

8  Archiv  f.  Kinderh.,  1900,  XXX,  324. 

»  Gaz.  des  liopiteaux,  1878,  LI,  66;  75. 


96  THE  DISEASES  OF  CHILDREN 

surrounded  by  a  distinct  albuminous  membrane.  There  is  clearly  some 
form  of  coating  which  prevents  their  coalition  one  with  another,  but  the 
exact  nature  of  this  is  not  known.  Abderhaklen  and  Voltz^  maintain  that 
it  is  not  casein,  and  perhaps  is  a  mixture  of  different  proteins.  Chemic- 
ally the  fat  consists  principal!}^  of  the  oleate,  myristate,  palmatate  and 
stearate  of  glycerole,  the  first  being  especially  abundant.  The  others, 
as  well  as  the  volatile  acids — butyric,  capric,  caproic,  and  caprylic — are 
present  in  small  amount  as  compared  with  cow's  milk  (Ruppel)  f  viz.,  2.5 
per  cent,  of  the  total  fat  in  human  milk;  27  per  cent,  in  cow's  milk 
(Morse  and  Talbot).^  The  proportion  of  the  total  fat  in  the  milk  is 
capable  of  great  variation,  more  than  that  of  any  other  constituent.  The 
percentages  may  certainly  range  from  2  up  to  5  or  even  more  in  milk 
which  may  yet  be  called  healthy  for  practical  purposes.  Not  infre- 
quently these  limits  are  much  exceeded,  the  percentage  dropping  occasion- 
ally to  1.5  or  even  less,  while  in  one  instance  I  observed  it  exceed  11  in 
milk  otherwise  normal. 

Sugar. — The  sugar  present  in  human  milk  is  identical  with,  or  closely 
allied  to,  the  lactose  occurring  in  cow's  milk.  Its  proportion  is  less 
liable  to  vary  than  that  of  fat  and  protein,  and  is  fairly  fixed  at  from  6  to  7 
per  cent,  in  healthy  milk.  Variations  decidedly  below  or  above  these 
figures  sometimes  occur. 

Protein. — The  protein-constituent  of  human  milk  is  far  from  being 
a  simple  one  and  its  chemistry  is  not  yet  fully  understood.  The  total 
protein-matter,  as  studied  by  later  and  more  accurate  methods,  may  be 
given  as  from  1  per  cent,  to  2  per  cent,  within  entirely  normal  limits,  and 
with  a  decided  capability  of  variation  from  these  figures.  A  per- 
centage of  3.5  or  even  more  is  not  uncommon,  and  is  sometimes  digested 
well,  though  oftener  not.  Two  principal  protein  bodies  are  uniformly 
recognized :  casein  and  lactalbumin.  There  exists  in  addition  the  protein 
substance  frequently  described  by  some  writers  as  "lactoglobulin," 
and  still  others  have  been  reported.  Wroblewski^  describes  one  rich 
in  sulphur  which  he  called  ''opalisin."  For  practical  purposes,  however, 
only  the  first  two  need  be  considered.  One  of  the  principal  characteristics 
of  human  milk  as  compared  with  cow's  milk  is  the  relatively  large 
quantity  of  lactalbumin  present,  the  relation  which  the  amount  bears 
to  that  of  casein  being,  according  to  Lehmann^  as  5  to  12;  albumin  with 
lactoglobulin  0.5  per  cent.;  casein  1.2  per  cent.  Konig''  gives  lactal- 
bumin 1.21  per  cent.,  casein  0.80  per  cent.,  while  in  cow's  milk,  according 
to  the  same  authority,  the  figures  are  0.51  per  cent,  and  2.88  per  cent, 
respectively.  Ciccarelli'^  found  lactalbumin  from  62.1  to  73.1  per  cent, 
and  casein  from  26.9  to  37.9  per  cent,  of  the  total  protein.  The  results 
obtained  by  different  investigators  are  clearly  by  no  means  uniform,  but 
all  agree  that  in  human  milk  the  percentage  of  lactalbumin  as  compared 
with  that  of  casein  is  greater  than  obtains  in  cow's  milk.  Average  figures 
would  probably  give  lactalbumin  and  globuHn  39  to  44  per  cent. ;  casein  41 
per  cent.;  residual  nitrogen  15  to  20  per  cent.  (Talbot).^ 

The  casein  is  a  nucleoalbumin  which  is  held  in  suspension,  but  not 

1  Zeit.  f.  phys.  Chem.,  1909,  LIX,  13. 

2  Zeit.  f.  Biol.,  1895,  XXXI,  1. 

^  Diseases  of  Nutrition  and  Infant  Feeding,  1915,  107. 

'  Zeit.  f.  phvs.  Chem.,  1898-99,  XXVI,  308. 

5  Arch.  f.  d.  gesammte  Physiol.,  1894,  LVI,  577. 

8  Chem.  d.  menschl.  Nahrungs-u.  Genussmittel,  1903,  110. 

7  La  PeJiatria,  1908,  VI,  12.      . 

8  Amer.  Jour.  Dis.  Child.,  1914,  VII,  445. 


HUMAN  MILK  97 

dissolved,  in  the  milk-plasma.  It  is  believed  that  it  is  not  entirely  iden- 
tical with  the  casein  of  cow's  milk,  being  not  so  readily  coagulated  by 
acids,  salts  or  rennet,  and  the  coagulum  formed  being  fine  and  loose,  and 
dissolving  readily  in  an  excess  of  acid.  On  the  other  hand,  it  has  been 
claimed  that  this  depends  upon  the  diverse  percentages  present  in  the  two 
forms  of  milk  and  the  relative  difference  in  the  amounts  of  lactalbumin 
and  of  salts.  Whatever  the  chemical  differences  may  be,  the  work  of 
Bordet,^  Wassermann^  and  others,  has  shown  from  a  biological  standpoint 
that  dissimilarities  do  exist  between  the  caseins  of  different  mammalian 
milks.  The  experiments  have  demonstrated,  that  whereas  the  blood- 
serum  of  animals  sensitized  to  one  mammalian  milk  will  react  with  the 
protein  of  the  milk  of  this  species,  it  will  not  do  so  with  other  species. 

The  lactalbumin  is  in  solution  in  the  milk.  It  is  alhed  to  or  identical 
with  serum-albumin. 

Mineral  Matter. — The  salts  of  milk  are  a  somewhat  complex  sub- 
stance. A  study  of  those  of  human  milk  by  Harrington  and  Kinnicutt' 
gave  the  following  results: 

Table  31. — Composition  of  the  Mineral  Matter  of  Human  Milk 
(Harrington  and  Kinnicutt) 

Calcium  phosphate 23 .  87 

Calcium  silicate 1 .  27 

Calcium  sulphate 2 .  25 

Calcium  carbonate 2.85 

Magnesium  carbonate 3 .  77 

Potassium  carbonate 23.47 

Potassium  sulphate 8 .  33 

Potassium  chloride 12 .  05 

Sodium  chloride 21 .  77 

Iron  oxide  and  alumina 0 .  37 

100.00 
Another  reliable  analysis  by  Soldner"*  is  as  follows : 

Table  32. — Percentages  of  Mineral  Matter  in  Hum.\n  Milk 

(Soldner) 

Potassium  oxide 0 .  0884 

Sodium  oxide 0.0357 

Calcium  oxide 0.0378 

Magnesium  oxide 0 .  0053 

Ferric  oxide 0.0002 

Phosphoric  oxide " 0.0031 

Sulphuric  oxide 0.0090 

Chlorine 0.0591 

A  series  of  analyses  by  Holt,  Courtney  and  Fales^  of  milk  of  the  mid- 
dle portion  of  lactation  gave  the  following  results: 

Table  33. — Percentages  of  Mineral  Matter  in  Human  Milk 
(Holt,  Courtney  and  Fale?) 

Calcium  oxide 0.0458 

Magnesium  oxide 0.0074 

Phosi)horic   oxide 0. 0345 

Sodium  oxide 0 .  0132 

Potassium  oxide 0 .  0609 

Chlorine 0.0358 

Total  ash 0.2069 

»  Ann.  dc  I'Instit.  Pasteur,  1899,  XIII,  22.5. 

2  Vorhandl.  XVIII,- Cong.  inn.  Med.,  1900,  .501. 

•'  Kotch,  Pediatrics,  1901,  i:30. 

■'  Zeit.  f.  Biol.,  1902,  XLIV,  (il. 

5  Amer.  Jour.  Dis.  Child.,  1915,  X,  229. 


98  THE  DISEASES  OF  CHILDREN 

Probably  the  amounts  of  the  ingredients  vary  much  in  different  milks, 
and  certainly  in  the  fore-milk  and  the  last  milk  of  a  single  nursing.  The 
total  quantity  of  mineral  matter  in  human  milk  is  likewise  subject  to 
decided  variation  within  normal  limits,  from  0.15  to  0.25  per  cent, 
being  a  not  unusual  range.  Human  milk  as  compared  with  that  of  the 
.  cow  is  poorer  in  calcium  and  in  phosphorus,  but  possesses  a  larger  amount 
of  iron.  The  phosphorus  in  human  milk  is  to  a  great  extent  in  a  different 
state  from  that  contained  in  cow's  milk.  It  exists  largely  in  organic 
combination,  and  is  believed  to  be  chiefly  in  the  form  of  lecithin  and 
nucleone,  both  of  which  are  in  small  amount  in  cow's  milk.  About  77 
per  cent,  of  the  phosphorus  in  human  milk  is  in  organic  combination, 
against  about  27  per  cent,  in  cow's  milk. 

Citric  Acid. — This  is  present  in  an  average  amount  of  0.05  per  cent. 
(Scheibe).i 

Ferments. — It  seems  probable  from  the  investigations  of  later  years 
that  various  ferments  and  allied  bodies  play  a  role  of  some  importance 
in  rendering  human  milk  better  suited  than  cow's  milk  for  the  needs  of 
the  infant's  economy.  This  is,  however,  very  uncertain,  since  cow's 
milk,  at  least,  appears  to  be  as  digestible  after  boihng,  which  destroys 
the  ferments,  as  before.  Moreover  the  difficulty  in  keeping  the  milk 
from  the  action  of  bacteria  renders  the  study  very  difficult,  inasmuch 
as  these  may  produce  the  same  effect  as  do  the  ferments  (Morse  and 
Talbot).^  A  diastatic  ferment,  amylase,  reported  by  Bechamp^  and 
others,  is  claimed  not  to  be  present  in  cow's  milk.  A  fat-splitting  fer- 
ment, lipase,  is  stated  by  Marfan  and  Gillet^  to  be  active  in  human  milk, 
and  but  slightly  so  in  cow's  milk.  One  which  decomposes  salol  is 
described  by  Nobecourt  and  Merklen^  as  present  in  human  milk,  but 
absent  from  cow's  milk.  The  existence  of  this  ferment  is  questionable. 
Moro  and  Hamburger^  found  one  which  coagulates  fibrin,  likewise  absent 
from  cow's  milk.  A  proteolytic  ferment  is  described  by  Babcock  and- 
RusselF  and  others,  and  a  glycolytic  ferment  by  Spolverini^  as  present  in 
both  kinds  of  milk.  Superoxidase,  peroxidase  and  reductase  occur  in 
both  human  and  cow's  milk. 

Protective  and  Other  Bodies. — Moro^  showed  that  although  no 
bactericidal  substances  were  to  be  found  in  human  milk,  yet  that  the  blood- 
serum  of  breast-fed  children  exhibited  a  bactericidal  power  much  greater 
than  that  of  those  artificially  fed,  and  that  the  former  do  not  contract 
pyogenic  diseases  so  easily.  The  protective  power  would  appear  to  be 
drawn  from  the  mother's  milk.  Diphtheria  antitoxin  is  found  in  the  milk 
of  immunized  animals,  and,  indeed,  the  well-known  comparative  immu- 
nity of  early  infancy  as  regards  many  of  the  infectious  diseases  probably 
depends  in  part  on  the  presence  in  the  breast-milk  of  immunizing  sub- 
stances, and  the  passage  of  this  into  the  serum  of  the  child.  Specific 
agglutinins  are  also  probably  transmitted  to  the  child  through  the  mother's 
milk. 

1  Ref.  Morse  and  Talbot,  Diseases  of  Nutrition  and  Infant  Feeding,  1915,  110. 

^  Loc.  cit.,  116. 

3  Compt.  rend,  de  I'acad.  des  sci.,  1883,  XCVI,  1508. 

*  Marfan,  I'Allaitement,  1903,  31. 

5  Rev.  mens,  des  malad.  de  I'enf.,  1901,  XIX,  138. 

6  Wien.  klin.  Wochenschr.,  1902,  No.  5,  121. 

'  Rep.  Wisconsin  Agric.  Station,  1898.  Ref.  Raudnitz,  Ergeb.  d.  Physiol.,  1903, 
II,  1  Abt.,  285. 

8  Archiv  de  m^d.  des  enf.,  1901,  IV,  705. 
3  Jahrb.  f.  Kinderh.,  1902,  LV,  396. 


HUMAN  MILK  99 

Caloric  Value.^ — According  to  the  estimations  of  Schlossmann^ 
the  average  value  of  a  liter  of  human  milk  in  large  calories  is  782  (740 
calories  per  quart),  while  that  of  average  cow's  milk  may  be  assumed  as 
about  670  calories  (654  per  quart).  Heubner-  gives  700  calories  (663  per 
quart)  for  human  milk  and  690  (653  per  quart)  for  cow's  milk.  (See 
Caloric  Value  of  Cow's  Milk,  p.  110.)  The  caloric  value  of  the  indi- 
vidual milk-elements  is  considered  elsewhere  (pp.  53  and  123). 

Action  of  the  Different  Constituents  of  Human  Milk.— (See 
also  pp.  48  and  127.) 

Water. — The  large  percentage  of  water  in  the  milk  indicates  the  need 
of  the  infant  especially  in  that  particular.  Concentrated  food  is  not 
as  easily  assimilated  as  a  rule,  even  though  the  actual  amount  of  sohd 
matter  ingested  is  not  altered,  and  the  work  thrown  upon  the  excretory 
organs  is  also  increased  if  sufficient  water  is  not  ingested.  The  amount 
of  water  required  by  an  infant  is  proportionately  many  times  greater 
than  in  adult  hfe.  There  is  little  need,  however,  of  water  given  by  itself 
when  the  diet  is  entirely  liquid,  since  enough  is  obtained  in  the  food;  but 
for  other  reasons  it  is  well  to  accustom  an  infant  to  it. 

Fat. — One  of  the  functions  of  the  fat  of  the  milk  is  that  of  increasing 
the  weight  of  the  body  by  the  deposition  of  it  in  the  tissues.  It  is  also 
needed  for  the  proper  formation  of  certain  tissues,  notably  of  the  nervous 
and  osseous  systems.  A  still  more  important  function  is  the  sustaining 
of  the  body-temperature.  As  already  stated  (p.  49)  this  object  is  gained 
by  metabolic  processes  much  more  easily  from  the  consumption  of  fat 
than  from  that  of  protein.  This  leaves  the  latter  for  the  object  for  which 
it  was  primarily  intended;  i.e.,  the  formation  of  nitrogenous  tissue. 
A  deficiency  in  the  amount  of  fat  in  the  breast-milk  requires  that  a  very 
much  larger  amount  of  protein  or  of  carbohydrate  must  be  ingested  than 
the  needs  of  the  child  in  other  respects  demand,  or  perhaps  than  its  digest- 
ive powers  will  tolerate. 

Another  result  of  a  proper  amount  of  fat  in  the  milk  is  a  normal  con- 
dition of  the  stools,  which  always  contain  a  considerable  quantity  of  it. 
Too  little  fat  is  liable  to  result  in  constipation.  On  the  other  hand, 
too  high  a  percentage  of  fat  is  prone  to  produce  disturbance  of  the  gastric 
digestion   and   diarrhea,    or   sometimes   constipation   with   soap-stools. 

Sugar. — Like  the  fat  the  function  of  sugar  is  the  production  of  heat 
needed  by  the  child.  To  a  considerable  extent  it  may  replace  the  fat, 
both  for  this  purpose  and  for  the  formation  of  new  fatty  tissue.  Yet 
an  infant  who  must  rely  for  any  length  of  time  upon  sugar  to  make  up 
for  a  deficiency  of  fat  in  the  milk  is  liable  to  suffer  eventually ;  for,  even 
though  gaining  in  weight,  tissue-formation  is  prone  to  be  defective,  and 
the  strength  is  below  normal.  What  is  said  here  of  the  sugar  natural 
to  human  milk  applies  equally  well  in  a  large  degree  to  other  varieties, 
as  well  as  to  the  starchy  food  used  later  in  infancy,  since  this  latter  must 
be  converted  into  sugar  before  it  can  be  absorbed.  The  effect  of  other 
sugars  and  of  starch  upon  digestion  are  considered  more  fully  elsewhere. 
(See  pp.  49  and  128.) 

Protein. — The  protein  is  the  essential  tissue-producing  substance 
of  the  milk,  since  it  is  the  only  one  containing  nitrogen.  Too  low  a 
percentage  of  protein  is  certain  to  be  followed  eventually  by  mahuitri- 
tion  in  some  form,  even  though  the  infant  may  show  no  wasting.  Pro- 
tein produces  heat  in  its  consumption.  Consequently  an  infant  could 
sustain  life  and  weight  for  a  time  on  a  diet  solelv  proteid  in  nature.     To 

1  Arch.  f.  Kiiiderh.,  1900,  XXX,  324. 
2Lehrb.  d.  Kinderh.,  1911,  51. 


100  THE  DISEASES  OF  CHILDREN 

accomplish  this,  however,  so  large  an  amount  is  required  that  the  gen- 
eral condition  of  the  child  would  almost  certainly  be  harmfully  affected 
in  some  way;  and  for  the  production  of  heat  the  other  elements  of  the 
food  should  be  relied  upon.     (See  p.  50.) 

Mineral  Matter. — Although  the  entire  purposes  of  the  salts  are  not 
understood,  yet  they  certainly  play  an  important  and  essential  part  in 
nutrition.  The  salts  of  calcium  are  required  for  the  formation  of 
osseous  tissue.  In  addition  calcium  in  the  milk  is  a  requisite  for  the 
proper  action  of  rennet.  Phosphorus,  too,  is  needed  for  the  osseous  and 
the  nervous  structures.  The  deficiency  in  the  iron  of  the  milk  is  made  up 
by  the  withdrawal  bj^  the  system  of  the  iron  stored  in  the  liver. 

Bacteria  in  Milk. — Healthy  human  milk  generally  contains  a  few 
bacteria.  This  has  been  shown  by  Honigmann,^  Cohn  and  Neumann, - 
Ringel,^  Kosthn,''  and  others.  The  germs  make  their  way  in  through  the 
nipple.  Consequently  the  first  milk  drawn  by  the  child  when  nursing 
is  that  in  which  they  are  contained.  The  remaining  milk  is  generally 
sterile.  The  principal  germs  found  are  the  staphylococcus  albus  and, 
less  commonly,  aureus  (Kostlin).  For  practical  purposes  human  milk 
may  be  considered  germ-free.  When  the  mammary  gland  is  suppurating 
the  number  of  germs  in  the  milk  is  necessarily  much  increased.  This  may 
also  sometimes  be  true  where  the  woman  is  the  subject  of  sepsis.  Certain 
pathogenic  germs,  as  those  of  tuberculosis  and  typhoid  fever,  may  very 
exceptionally  occur  in  the  milk  of  women  suffering  from  these  diseases. 
Wang  and  Coonley^  in  450  examinations  of  the  milk  of  28  tuberculous 
women  found  tubercle  bacilli  in  no  instance  with  1  possible  exception. 
Uhlenhuth  and  Mulzer'^  inoculating  rabbits  with  milk  from  syphilitic 
women  were  able  to  produce  in  them  the  lesions  of  syphilis. 

Characteristics  and  Effects  of  Poor  Milk. — Owing  either  to  the 
individual  peculiarity  of  the  baby,  or  to  faults  in  the  quality  of  the  milk, 
some  infants  fail  to  digest  the  maternal  secretion  but  thrive  on  that  of  a 
wet-nurse;  or  the  milk  which  disagrees  with  one  infant  suits  another 
perfectly.  An  analysis  of  the  milk  will  often  show  in  what  the  fault  in 
composition  consists.  In  other  instances  the  milk  is  found  to  be  chemic- 
ally normal,  yet  does  not  agree.  Much  more  important  than  the  analysis 
is  the  character  of  the  symptoms  produced,  and  especially  a  failure  of 
the  normal  gain  in  weight;  and  one  can  afford  to  temporize  with  moderate 
diarrhea,  vomiting,  or  colic,  rather  than  wean  the  baby  if  the  weight  is 
satisfactory.  Of  course  this  does  not  apply  if  the  symptoms  are  severe. 
One  of  the  faults  of  the  milk  is  that  of  being  too  rich  in  both  fat  and  pro- 
tein; the  percentage  of  sugar  not  varying  materially  in  the  milk  of  different 
women.  This  over-rich  milk  is  oftenest  observed  in  the  case  of  women 
who  are  taking  too  little  exercise,  eating  too  freely,  and  digesting  well. 
The  infant  exhibits  the  various  symptoms  of  indigestion  and  often  loses 
weight.  Submitting  to  a  proper  dietetic  and  hygienic  regimen  will 
usually  correct  the  difficulty.  Occasionally  it  is  possible  to  relieve  the 
infant's  condition  by  allowing  it  to  nurse  for  a  few  minutes  only  and  then 
giving  it  a  bottle  of  water,  thus  diluting  the  milk  in  the  stomach.  Less 
often  the  fat  is  increased  and  the  protein  normal  in  amount.  Sour 
vomiting  and  curds  in  the  stools  are  then  liable  to  appear. 

1  Zeit.  f.  Hygiene  u.  Infectionskrankh.,  1893,  XIV,  207. 

2  Virchow's  Archiv.,  1891,  CXXVI,  391. 

3  Miinch.  ined.  Woch.,  1893,  513. 

*  Arch.  f.  Gvnak.,  1897,  LIII,  201. 

5  Jour.  Amer.  Med.  Assoc,  1917,  LXIX,  531. 

«  Deut.  med.  Woch.,  1913,  XXXIX,  879. 


HUMAN  MILK 


101 


c 


o 


liC 


\ 


Much  more  frequently,  however,  a  poor  milk  is  supplied  containing 
either  a  low,  or  oftener  a  high  percentage  of  protein  and  a  very  low  per- 
centage of  fat.  Poor  milk  of  this  sort  is  scanty  in  quantity,  and  is  seen 
oftenest  in  neurotic,  debilitated,  anemic,  over-worked,  or  over-anxious 
women.  The  infants  do  not  thrive  and  may  be  constipated  and  exhibit 
no  symptoms  of  indigestion  whatever,  or  may  sometimes  suffer  (if  the 
protein  is  in  large  amount)  from  intestinal  indigestion  with  colic  and 
loose  stools,  often  brownish  and  offensive. 
Vomiting  is  not  a  frequent  symptom. 
Efforts  should,  of  course,  be  made  to  im- 
prove the  quality  of  the  milk  (p.  106)  by 
attending  to  the  condition  of  the  mother; 
but  when  the  trouble  continues  after  the 
early  weeks  of  the  child's  hfe  it  is  not 
likely  that  these  efforts  will  be  successful. 

Examination  of  the  Breast=milk. 
There  are  several  indications  that  milk 
is  being  secreted  in  sufficient  quantity. 
If  the  breasts  fill  up  well  and  become 
hard  and  round  between  the  nursings;  if 
the  infant  nurses  from  but  one  breast  and 
is  satisfied  by  that;  and  if  it  does  not  re- 
quire more  than  20  minutes  to  complete 
its  nursing,  the  probabihty  is  that  the 
milk  secreted  is  abundant.  On  the  other 
hand,  if  the  breast  remains  soft  and 
flabby;  if  the  child  nurses  much  too  long 
and  seems  dissatisfied,  or  will  nurse  but  a 
few  minutes  and  then  refuse  to  make 
further  efforts;  if  it  cries  much,  yet  seems 
to  have  no  colic  or  other  disease;  and  if  it 
does  not  gain  in  weight,  yet  has  no  illness 
to  account  for  this,  the  milk  is  probably 
insufficient  in  quantity  or  perhaps  poor  in 
quality. 

A  direct  method  is  to  pump  out  or 
press  out  the  breast-milk  and  measure 
it.  Yet  this  is  often  unsatisfactory  owing 
to  the  frequently  experienced  difficulty 
in  emptying  the  breast  in  this  way.  A 
rough  estimation  of  the  character  and 
quantity  of  the  milk  may  be  made  by 
seeing  with  what  degree  of  ease  and  in 
what  quantity  it  can  be  expressed  from  the  breast  by  the  hand.  The 
"thumb-nail  test"  also  is  serviceable  to  a  limited  extent,  a  large  drop 
— not,  however,  the  first  which  comes  from  the  breast — being  drawn 
upon  the  thumb  nail,  and  its  color,  transparency  and  coherence  indi- 
cating the  richness  of  the  milk.  Normal  milk  should  be  white  and 
opaque,  and  should  preserve  the  drop-form  oven  when  the  nail  is 
held  vertically.  All  this,  however,  is  but  approximate.  The  only  sat- 
isfactory method  (jf  determining  what  amount  of  milk  the  child  really 
obtains  is  by  weighing  it  or  the  mother  immediately  before  and  inimeili- 
ately  after  the  nursing,  using  scales  which  record  ounces. 


Fig.   17. — Cream  Galge  and 

Lactometer. 
For  approximate  analysis  of  hu- 
man milk.     {Holt,  Arch,  of  Pediat., 
1893,  AM93;  202.) 


102 


THE  DISEASES  OF  CHILDREN 


As  regards  the  examination  of  the  milk  in  other  respects,  the  reaction 
is  tested  bj'  Utmiis  paper,  or  still  more  accurately  by  a  solution  of  phenol- 
phthalein.  The  specific  gravity  is  determined  by  any  small  specific 
gravity  glass  which  does  not  require  much  milk.  A  small  urinometer 
(Fig.  17)  answers  every  purpose.  The  accurate  scientific  estimation  of 
the  percentages  of  the  milk-elements,  with  the  exception  of  the  fat,  can 
be  made  only  by  one  having  a  considerable  knowledge  of  chemistry. 
Various  methods  may  be  employed,  however,  which  give  satisfactory 
approximate  results.  The  milk  to  be  examined  should  preferably  be 
all  that  can  be  pumped  or  expressed  from  the  breast.  A  less  accurate 
procedure  is  to  allow  the  infant  to  nurse  for  a  moment,  wash  the  nipple, 
and  then  pump  out  a  small  portion  of  the  middle  milk.  This  should  be 
kept  on  ice  in  a  sterilized,  well-corked  bottle,  and  a  similar  quantity  of 
several  different  nursings  added  to  it  during  the  day. 

Inasmuch  as  the  percentages  of  sugar  and  of  mineral  matter  are  so 
nearly  constant,  it  is  only  the  variation  in  the  fat  and  protein  which  we 
need  determine  for  practical  purposes.  Holt^  devised  a  simple  method  for 
the  approximate  examination  of  human  milk.  The  principle  of  this  de- 
pends upon  the  mutal  relationships  of  the  fat,  the  protein  and  the  specific 
gravity.  The  latter  is  first  determined  in  the  way  explained.  The  per- 
centage of  fat  is  then  estimated  by  a  small  creamometer.  This  is  a 
cylindrical  vessel  (Fig.  17)  holding  10  c.c.  (0.34  fl.oz.)  and  graduated  to 
show  the  percentage  of  cream  present.  It  is  filled  with  milk  to  the  zero 
mark,  corked  well  and  allowed  to  stand  at  the  room-temperature  of 
about  70°F.  (21.1°  C.)  for  24  hours.  The  percentage  of  cream  is  then 
read  off  and  that  of  fat  calculated  on  the  basis  that  this  will  be  to  that 
of  the  cream  as  3  is  to  5;  i.e.,  5  per  cent,  of  cream  equals  3  per  cent,  of 
fat.  The  average  amount  of  cream  should  be  7  per  cent.  Having  deter- 
mined in  this  way  the  fat-percentage  and  the  specific  gravity,  the  other, 
factor,  the  amount  of  protein,  can  be  readily  estimated  by  the  following 
rule  of  proportion;  viz.  that  the  fat  varies  inversely  and  the  protein 
directly  with  the  specific  gravity;  that  is  to  say,  the  higher  the  fat- 
percentage,  the  lower  will  be  the  specific  gravity,  and  the  higher  the 
protein-percentage,  the  higher  will  be  the  specific  gravity.  For  instance, 
if  the  fat  is  normal,  a  high  specific  gravity  must  be  due  to  a  high  protein- 
percentage.  If  the  specific  gravity  is  high  and  the  fat  low,  the  protein 
may  be  assumed  as  normal,  since  the  low  fat-percentage  accounts  for  the 
high  specific  gravity.  Or,  again,  if  the  specific  gravity  is  normal  and  the 
fat  low,  the  protein  must  be  low,  otherwise  the  low  fat-percentage  would 
have  increased  the  specific  gravity  above  normal.  The  following  table 
shows  in  a  convenient  manner  the  various  relations  which  may  be  present : 

Table  .34. — Method  for  Approximate  Analysis  op  Human  Milk 


Specific  gravity,  70°  F. 


Cream,  24  hr. 


Average 

Normal  variations .  .  . 
Normal  variations .  .  . 
Abnormal  variations . 

Abnormal  variations . 

Abnormal  variations. 

Abnormal  variations. 


7% 
8%-12% 
5%-  6% 
High 

(above  10%) 
Low 

(below  5%) 
High  (above  1.032)  High 


1.031 

1 . 028-1 . 029 

1.032 

Low  (below  1.028) 

Low  (below  1.028) 


High  (above  1.032)  Lqw 


Protein,  estimated 


1.25% 
Normal  (rich  milk) 
Normal  (fair  milk) 
Normal  or  slightly  below 

Very  low 

(very  poor  milk) 
Very  high 

(very  rich  milk) 
Normal  (or  nearly  so) 


'  Arch,  of  Fed.,  1893,  X,  193.     Diseases  of  Children,  1916,  141. 


HUMAN  MILK 


103 


=D 

|9 
=•8 

N 

=4 
■3 
■2 

i-i 

^0 


The  method  detailed  is  intended  to  be  only  an  approximate  one,  and  the 
fat  and  protein  of  the  milk  may  be  determined  with  sufficient  accuracy  by 
other  procedures  which  are  but  little  more  difficult  and  are  quite  within 
the  power  of  one  who  is  not  a  chemist.  For  the  estimation  of  the  fat  a 
serviceable  instrument  is  the  Babcock  centrifuge,  which,  however, 
requires  17.6  c.c.  (0.598  fl.oz.)  of  milk  (Fig  18).  A  similar  apparatus 
needing  but  5  c.c.  (0.169  fl.oz.)  (Fig.  19)  is  the  milk-testing 
glass  supplied  for  this  purpose  with  the  small  Bausch  and 
Lomb  centrifugal  machine  designed  for  centrifugal  analy- 
sis, and  employing  the  solutions  recommended  by  Leffmann 
and  Beam. 

The  principle  consists  in  the  oxidation  of  the  sugar  and 
protein  by  sulphuric  acid,  after  the  addition  of  fusel  oil  and 
hydrochloric  acid.  After  centrifugation  for  a  few  minutes 
the  fat  rises  into  the  neck  of  the  tube  and  the  percentage 
may  be  read.^ 

The  percentage  of  protein  may  be  determined  directly 
with  reasonable  accuracy  by  the  method  described  by  Boggs.^ 
This  consists  in  precipitating  it  with  phosphotungstic  and 
hydrochloric  acids  in  an  Esbach  tube  and  reading  off  the 
percentage  after  24  hours. 

Conditions  Altering  the  Character 
of  the  Milk.' — Some  of  the  abnormahties 
in  composition  already  described  (p.  100) 
depend  upon  various  known  causes,  among 
which  may  be  enumerated  the  following: 
(a)  Period  of  Lactation. — This  exercises 
some  influence  upon  the  composition  of  the 
milk;  yet,  as  a  rule,  not  to  any  very  con- 
siderable extent.  The  statistics  of  different 
investigators  are  not  entirely  in  accojd. 
The  colostrum  of  the  first  few  daj^s,  as  we  have  seen,  is 
rich  in  protein  and  in  salts  (p.  93).  This  is  modified 
rapidly  after  the  3d  day,  and  by  the  end  of  2  weeks  an 
average  milk  is  obtained  which  varies  but  little,  although 
individual  milks  may  change  considerably  and  irregularly 
from  time  to  time.  According  to  investigations  made  by 
Camerer  and  Soldner^  (57  analyses),  V.  and  J.  S.  Adriance^ 
(120  analyses),  and  Schlossmann^  (218  analj^ses),  there 
occurs  a  shght  but  steady  diminution  in  the  percentage 
of  protein  beginning  2  to  4  weeks  after  child-birth,  the 
loss  by  the  7th  month  of  lactation  being  about  0.5  per 
cent.  Toward  the  end  of  lactation  there  is  a  decided 
diminution  in  the  amount  of  protein,  the  percentage  of  sugar  slightly 
increases,  while  the  mineral  matter  diminishes.  The  percentage  of  fat 
shows  no  regular  change,  unless  it  may  be  a  slight  decrease  (Camerer 
and  Soldner).  Sharplcss  and  Darling*^  find  no  noteworthy  alteration  in 
any  of  the  constituents  which  can  be  called  characteristic  of  different 
periods  of  lactation. 

>  See  Formulai  supplied  t)y  the  Bausch  and  Lomb  Optical  Co.  with  the  instrument. 

2  Johns  Hopk.  Hosp.  IJuU.,  190i),  XVI.  I;i-12. 

3  Zeit.  f.  Biol.,  LS9.S,  XXXVI,  277. 
*  Arch,  of  I'ed.,  1,S<.)7,  XIV.  22. 

^  Arch.  f.  Kindcrh.,  1900,  XXX,  288. 

8  Boston  Medical  and  Surg.  Journ.,  1903,  CXLVIII,  416. 


Vu..  IS.— 
Bab  cock's 
m ilk-test 
Bottle. 
(D.  H.  Burrel 
and  Co.) 


Fig.  19.— 
Flask  for 
Bausch  .^^nd 
Lomb  Centri- 
fuge. 

For  detormin- 
iiiK  the  fat-per- 
centage of  milk. 


104 


THE  DISEASES  OF  CHILDREN 


(h)  Intervals  of  Nursing  and  Time  at  the  Breast.^ — Peligot^  has  shown 
by  experiments  with  asses'  milk  that  the  longer  the  fluid  is  in  the  udder; 
i.e.,  the  longer  the  interval  between  nursings;  the  more  watery  it  becomes. 
The  same  is  true  of  human  milk.  It  is  apparently  especially  the  fat  which 
is  increased  in  amount  by  shortening  the  nursing  intervals.  There  is  a 
difference,  too,  in  the  milk  from  the  breast  at  the  beginning,  in  the  middle, 
and  at  the  end  of  nursing,  again  the  change  being  chiefly  in  the  fat. 
The  analyses  made  by  Mendes  de  Leon^  and  by  Adriance^  give  figures 
illustrating  the  truth  of  this.     Harrington's*  analysis  of  cow's  milk  tends 


T.^BLE   35.- 

—Fat-content  of  Human 

M 

[LK 

Mendes  de  Leon 
Fat,  per  cent. 

Adriance 
Fat,  per  cent. 

Full  breast     

2.62 
4.08 
6.02 

2.27 

Middle  milk     

2.79 

Nearly  empty  breast 

3.65 

to  confirm  this  difference  for  human  milk  since  similar  conditions  would 
naturally  exist. 

Table  36. — Fat-content  of  Cow's  Milk 
(Harrington) 


Fat, 
per  cent. 

Total  solids, 
per  cent. 

Water, 
per  cent. 

Ash, 
per  cent. 

Fore  milk 

3.88 
6.74 
8.12 

13.34 
15.40 
17.13 

86.66 
84.60 

82.87 

0.85 

Middle  milk 

0.81 

Strippings  

0.82 

(c)  Number  of  Pregnancies  and  Age  of  Mother. — According  to 
Adriance^  the  milk  of  women  between  20  and  30  years  of  age  is  slightly 
richer  in  fat  and  protein  and  shghtly  poorer  in  sugar  than  that  of  older 
women.  The  same  is  true  of  primiparae  as  compared  with  multiparae. 
The  differences,  however,  are  neither  very  material  nor  very  constant, 
and  may  be  disregarded  provided  only  that  the  health  of  the  mother  is 
good. 

(d)  Pregnancy. — This  generally  diminishes  the  quantity  of  the  milk 
secreted  and  affects  its  quality,  the  amount  of  fat  especially  being  re- 
duced, and  the  milk  sometimes  approaching  the  character  of  colostrum- 
milk.  In  other  cases  the  milk  remains  abundant  and  of  good  quality, 
and  the  infant  could  safely  be  kept  upon  the  breast;  but  this  is  not  the 
rule,  and  on  the  mother's  account  the  child  should  be  weaned. 

(e)  Menstruation. — No  certain  alteration  of  the  milk  follows  if  men- 
struation reappears.  In  some  cases  the  percentage  of  fat  is  diminished 
and  that  of  the  protein  and  of  the  sugar  increased  or  the  general  health 
of  the  infant  may  exceptionally  be  acutely  disturbed.  In  most  instances 
the  character  of  the  milk  is  entirely  unaffected,  or,  perhaps,  at  most 
only  during  the  days  when  the  menses  are  present.  Often  the  menses 
appear  but  once,  and  do  not  return  until  lactation  is  normally  over.     The 

1  Hermann,  Handb.  d.  Physiol.,  V,  Th.  1,  404.  Ref.  Rotch,  Keating's  Cyclop. 
Dis.  Child.,  1889,  I,  289. 

2  Zeit.  f.  Biol.,  1881,  XVII,  501. 

3  Loc.  cit.,  22. 

^  Rotch,  Pediatrics,  1901,  133. 
6  Loc.  cit.,  22. 


HUMAN  MILK  105 

greatest  caution,  therefore,  should  be  exercised  lest  weaning  be  hasty  and 
unnecessary.  If  acute  symptoms  develop  the  child  could  be  artificially 
fed  for  the  few  days  while  mentruation  lasts.  An  exhaustive  studj^  by 
Bamberg^  led  to  the  conclusion  that  there  is  no  reason  to  believe  that 
menstruation  makes  the  milk  harmful  to  the  infant.  (See  also  Causes 
making  Nursing  Inadvisable,  p.  86.) 

(/)  Diet. — Diet  often  exercises  great  influence  upon  the  character 
of  the  milk  secreted.  This  is,  however,  chiefl}^  upon  the  protein  and 
the  fat,  the  sugar  and  salts  being  little  affected.  Insufficient  nourish- 
ment of  the  mother  produces  milk  deficient  in  total  solids,  especially  the 
fat.  The  protein  is  either  diminished  or  increased  in  quantity.  So, 
too,  an  excessive  amount  of  liquid  taken  often  diminishes  the  total  solids 
in  all  particulars,  although  in  other  cases  the  amount  of  milk  is  much 
increased  without  any  diminution  in  the  percentage  of  the  solid  ingredients. 
An  abundant  and  rich  diet,  if  well  digested,  given  to  women  previously 
under-fed,  increases  both  the  fat  and  the  protein  and  the  quantity  of 
milk.  On  the  other  hand,  an  over-abundant  diet  sometimes  tends  either 
merely  to  increase  the  adipose  of  the  mother,  or  to  injure  the  quality 
of  the  milk  secreted  and  produce  indigestion.  It  has  been  thought  that 
the  percentages  of  fat  and  of  protein  are  increased  by  a  highly  nitrogenous 
diet,  but  diminished  by  a  vegetable  one,  and  that  a  diet  rich  in  digestible 
fat  also  increases  the  fat  in  the  milk.  It  is  questionable,  however,  whether 
any  such  alteration  in  diet  affects  any  of  the  milk-elements  except  in  the 
case  of  women  who  have  been  previously  long  under-fed.  It  is  possible 
that  certain  vegetables  which  possess  a  strong  odor  and  taste  may  com- 
municate these  to  the  mother's  milk,  which  may  thus  become  unpleasant 
to  or  disagree  with  the  child.  It  is  likely,  too,  that  some  women  exhibit 
idiosyncrasies  toward  certain  articles  of  food,  and  that  after  they  have 
partaken  of  them  their  milk  may  disagree  with  the  bab3^  These  are, 
however,  all  exceptions,  and  as  a  rule  a  healthy  nursing  woman  may  eat 
any  digestible  food  without  fear  of  any  special  influence  of  it  upon  the 
child. 

(g)  Exercise. — This,  too,  influences  the  character  of  the  milk  decid- 
edly. Deficient  exercise  combined  with  a  healthy  appetite  is  liable  to 
increase  the  percentages  of  protein  and  of  fat;  a  proper  amount  of  exer- 
cise to  decrease  an  excess,  if  the  woman  has  been  too  inactive;  excessive 
exercise,  with  constant  fatigue,  to  increase  the  protein. 

(h)  Mental  and  Nervous  Influences. — The  affect  of  these  is  greater 
than  perhaps  from  any  other  cause.  It  not  infrequently  happens  that 
fright,  anger,  sorrow,  or  other  great  emotion  will  quickl}'-  so  affect  the 
milk  that  the  infant  is  made  ill  by  it.  What  the  changes  are  is  not  cer- 
tainly known.  In  some  instances  there  is  a  sudden  great  diminution 
in  the  amount  of  the  total  solids,  especially  the  fat,  and  increase  in  that  of 
water.  In  others  the  protein  is  much  increased  in  amount.  In  some 
cases  there  seem  to  be  actual  toxic  changes  produced  in  the  milk.  It 
sometimes  even  happens  that  the  secretion  of  milk  is  quickly  ixnd 
permanently  arrested  by  some  emotional  cause,  or  maj^  have  its  qualit}' 
affected  and  its  amount  much  diminished  by  more  prolonged  nervous 
influences  such  as  worry,  repeated  fatigue,  and  the  like.  The  nervous 
mother  is  the  one  particularly  liable  to  have  a  milk  poor  in  fat  and  too 
rich  in  protein. 

{i)  Illnesses. — A  good  state  of  the  general  health  is  often  a  pre- 
requisite t(j  the  secretion  of  good  and  abundant  milk.     In  other  cases 

'  Zeit.  f.  Kinderh.,  Orig.,  1913,  VI,  424. 


106  THE  DISEASES  OF  CHILDREN 

the  milk  continues  unaffected  in  spite  of  the  mother  being  deUcate  and 
frail.  This  is  often  at  the  expense  of  the  mother.  Acute  temporary 
ailments  have  but  little  effect  upon  the  milk.  In  more  severe  febrile 
diseases  the  amount  of  milk  may  be  much  diminished  and  the  percentage 
of  fat  decreased  and  that  of  the  protein  increased. 

(j)  Drugs. — These  may  be  divided  into  those  which  influence  the 
secretion  of  milk  and  those  which  are  excreted  by  the  mammary  glands 
with  the  milk.  The  former  will  be  referred  to  again  in  considering  the 
modification  of  breast-milk  (see  below) .  Of  the  latter  it  may  be  said  that, 
contrary  to  the  opinion  among  the  laity,  few  drugs  pass  into  the  milk 
to  any  considerable  extent,  and  the  occurrence  is  so  irregular  and  un- 
certain that  efforts  at  medication  of  the  child  by  way  of  the  breast-milk 
would  be  unsatisfactory.  The  statements  of  investigators  are  largely  con- 
tradictory. The  following  conclusions  are  based  chiefly  upon  the  pub- 
lications of  Fehhng,^  Houselot,'  Engel,^  and  others. 

Alcohol  imbibed  in  very  large  amounts  may  appear  only  in  traces  in 
the  milk.  It  may,  however,  taken  in  this  way  bj'-  the  mother  or  wet- 
nurse  produce  serious  illness  in  the  infant.  Atropine,  hyoscine  and  colchi- 
cine pass  directly  into  cow's  milk  in  small  amounts,  and  probably  do  so 
in  human  milk  as  well.  Opium  taken  by  the  mother  very  rarely  has  any 
effect  on  the  child.  Yet,  as  cases  are  on  record  where  dangerous  action 
has  occurred,  it  is  best  to  administer  it  cautiously  and  in  doses  smaller 
than  usual.  Iodine,  given  to  the  mother  in  the  form  of  iodides  or  applied 
as  iodoform  in  a  dressing,  passes  readily  into  the  milk.  Bromine  does  so 
to  some  extent  (Rosenhaupt)*  and  occasionally  in  a  way  to  affect  the 
infant  seriously.  Mercury  has  practically  no  effect.  It  passes  to  the 
child  only  in  small  amount  and  after  prolonged  administration  to  the 
mother.  Chloral  has,  as  a  rule,  no  influence.  Any  effect  appears  only 
in  weakly  children  who  are  nursed  within  an  hour  after  the  ingestion  of 
the  drug  by  the  mother.  Arsenic,  antimony,  hexamethylenamine,  anti- 
pyrine,  and  phenacetin  pass  into  the  milk  to  a  limited  extent.  In  the 
form  of  arsphenamine  arsenic  appears  to  have  a  decided  effect  on  the  child 
in  some  instances.  Quinine  has  little  if  any  influence  on  the  infant  as  a 
rule,  and  only  when  given  to  the  mother  on  an  empty  stomach,  and  when 
her  child  is  still  in  its  1st  half-year.  Lead  and  iron  enter  the  milk  to 
some  extent.  Salicylic  acid  in  its  different  combinations  affects  it  very 
decidedly.  The  mineral  and  vegetable  acids  have  no  effect  upon  it.  The 
saline  purgatives  occasionally  pass  into  it  to  some  extent,  while  the  vege- 
table purgatives,  as  senna,  aloes,  rhubarb,  and  cascara,  as  a  rule  do  not 
(Gow).^  Chloroform  and  ether  appear  to  be  without  influence,  with  rare 
exceptions. 

Modification  of  Breast=milk.^ — ^From  what  has  been  stated  in 
previous  sections  it  is  evident  that  whereas  the  mother's  milk  may  often 
be  found  insufficient  or  insuitable  for  the  infant,  it  may  sometimes  be 
possible  in  various  ways  to  modify  the  secretion  in  quantity  or  quality 
and  thus  to  avoid  the  abandoning  of  nursing. 

Quantity.— A  threatened  drying  up  of  the  secretion  may  often  be  pre- 
vented by  seeing  that  the  breast  is  thoroughly  emptied  at  each  nursing, 
giving  both  breasts  if  the  milk  is  scant}^     There  is  no  better  stimulant 

1  Arch.  f.  Gynak.,  1886,  XXVII,  331. 
-  Rev.  prat,  d'obstet.  et  de  paediat.,  1901,  Nos.  1  and  2. 

3  Sommerfeld's  Handb.  d.  Milchkunde,  1909,  810.     Ref.  Morse  and  Talbot,  Dis- 
eases of  Nutrition  and  Infant  Feeding,  1915,  114. 
■•Arch.  t.  Kinderheilk.,  1904,  XL,  131. 
s  Practitioner,  1893,  L,  168. 


HUMAN  MILK  107 

to  increase  secretion  than  this.  The  taking  of  an  abundant  amount  of 
liquid  in  some  form  is  often  an  aid,  with  due  caution  that  this  does  not 
merely  increase  the  amount  while  diminishing  the  total  solids  in  a  breast- 
milk  already  poor  in  quality.  Milk  and  cocoa,  however,  have  no  advan- 
tage over  weak  tea  or  water,  so  far  as  quantity  is  concerned ;  and  in  the 
case  of  a  woman  already  well-nourished,  may  merely  result  in  making 
her  unduly  fat.  Malt  liquors  undoubtedly  have  a  decided  influence  in 
increasing  the  quantity  in  some  cases  and  may  be  used  for  this  purpose, 
with  caution  that  no  addiction  to  alcohol  is  established.  (See  also  p.  84.) 
In  all  under-nourished  women  a  generous  diet  should  be  given  ancl  over- 
work avoided.  In  women  of  a  nervous  temperament  the  life  should  be 
as  quiet  as  possible,  all  exciting  influences  avoided,  and  rest  at  night  be 
undisturbed,  the  care  of  the  infant  at  this  time  being  delegated  to  the 
nurse,  and,  if  it  seems  best,  the  night-feedings  being  of  artificial  food. 
With  all  nursing-women  care  should  be  taken  that  they  spend  a  consider- 
able part  of  each  day  quietly  in  the  open  air,  driving,  sitting,  or  taking 
easy  walks.  Among  other  methods  which  are  recommended  to  increase 
the  secretion  are  gentle  daily  massage  of  the  breasts,  faradization,  and  the 
administration  of  galactagogues.  Regarding  the  last  there  is  no  cer- 
tain evidence  that  any  of  these  are  of  value.  Experiments  upon  animals 
by  some  investigators  appear  to  show  such  power  in  the  administration 
of  corpus  luteum,  placenta,  the  posterior  lobe  of  the  pituitary  body,  and 
the  suprarenal  glands,  or  in  the  injection  of  milk,  but  these  have  not  been 
confirmed.  Pilocarpine,  cotton-seed,  anise,  and  other  drugs  have  been 
tried,  but  there  is  little  evidence  in  their  favor. 

Quality.— In  cases  where  the  milk  is  in  general  too  rich,  the  condition 
can  often  be  remedied  by  insisting  upon  a  more  active  life  with  abundant 
exercise,  and  by  reducing  the  amount  of  food  taken.  Lengthening  the 
interval  between  the  nursings  and  diminishing  the  total  sohds  ingested 
may  be  of  avail.  The  excess  of  'protein  so  common  in  defective  breast- 
milk  in  neurotic  women  can  sometimes  be  remedied  by  increasing  the 
amount  of  exercise  up  to  a  healthful  feeling  of  fatigue,  and  by  taking 
measures  to  relieve  the  nervous  condition.  If,  however,  the  exercise 
goes  beyond  this  point,  the  percentage  of  protein  may  be  increased. 
This  is  the  condition  of  the  milk  existing  in  the  over-worked  and  under- 
fed women  of  the  poorer  classes.  Here  an  increase  of  diet  and  of  rest  may 
bring  the  milk  closer  to  the  normal.  Influencing  the  protein-percentage 
by  the  diet  is,  however,  usually  unsuccessful  except  in  those  women  who 
are  over-fed  and  idle;  and  in  the  starvation  cases  in  which,  as  sometimes 
happens,  all  the  elements  of  the  milk  are  deficient  in  quantity,  instead  of 
the  protein  being  high  as  is  usually  the  case.  An  excessive  percentage  of 
Jal  can  be  lessened,  with  the  protein,  in  the  over-fed  and  idle  women 
referred  to,  by  reducing  the  total  amount  of  food  ingested  and  increasing 
the  exercise.  It  is  also  reduced  by  lengthening  the  nursing  intervals. 
When  the  amount  of  fat  is  deficient  little  can  usually  be  accomplished, 
except  in  the  starvation  cases,  where  an  abundant  diet  and  a  diminution 
of  work  may  increase  the  fat-percentage  with  that  of  the  protein  and  the 
total  secretion.  Alteration  of  the  diet  has  little  effect  on  the  secretion 
of  fat  in  women  already  well  nourished  and  exercising  sufficiently.  (See 
also  p.  105.)  The  amount  of  sugar  in  the  milk  cannot  be  intlucnced  with 
any  certainty.  It  is  less  variable  than  cither  the  fat  or  tiie  ijrotein.  In 
some  cases  the  administration  of  sugar  has  increased  the  percentage 
(Lust),^  in  others  not  at  all. 

'  Monatsschr.  f.  Kinderh.,  Orig.,  1912,  XI,  236. 


CHAPTER  IV 


ARTIFICIAL  FEEDING  IN  THE  FIRST  YEAR 

The  nourishment  of  an  infant  with  anything  other  than  the  secretion 
of  the  human  breast  is  properly  termed  "artificial  feeding,  or  "substitute 
feeding,"  The  problem  is  often  one  of  the  most  difficult  which  the  physi- 
cian encounters.  The  fact  that  we  are  dealing  with  a  diet  other  than  the 
natural  one  renders  an  absolute  solution  of  it  impossible,  since,  as  far  as 
our  present  knowledge  extends,  we  are  unable  in  any  way  to  construct 
a  food  which  is  exactly  Hke  human  milk.  Moreover,  we  have  to  do 
always  with  the  child  as  an  individual,  to  whom  general  rules  can  apply 
only  in  a  general  way.  Our  inabiUty  to  produce  a  food  for  infants  which 
can  be  looked  upon  in  any  way  as  a  standard  must  make  us  cautious  in 
forming  an  arbitrary  or  hasty  decision  regarding  the  propriety  or  im- 
propriety of  a  certain  method  of  feeding  in  a  given  case,  providing  the 
infant  is  actually,  and  not  only  apparently,  thriving  upon  its  food. 
Nothing  of  this  militates  against  the  effort  at  an  establishment  of  a  scien- 
tific basis  for  the  feeding  of  infants  in  general. 

COW'S  MILK 

Of  all  foods  the  milk  of  some  mammal  is  to  be  preferred  as  the  basis, 
since  it  is  in  this  class  that  the  natural  food  of  the  infant  belongs.  That 
of  various  animals  has  at  times  been  employed  in  different  countries  and 
for  various  theoretical  reasons,  the  ass,  goat,  sheep,  buffalo,  sow,  and  mare 
having  all  been  tried.  These  mammalian  milks  differ  from  human  milk 
in  various  particulars,  as  is  shown  by  the  following  table : 
Table  37. — Composition  op  Mammalian  Milk 
(Richmond)- 


Water, 
per 
cent. 

Fat, 
per 
cent. 

Sugar, 
per 
cent. 

Casein, 
per 
cent. 

Albumin, 
per 
cent. 

Ash, 
per 
cent. 

Cow 

Goat 

Ewe 

Buffalo 

Woman 

87.10 

86.04 
79.46 
82.63 
88.2 

89.80 
90.12 

91.50 

75.44 
81.63 

69.50 
86.55 

86.57 
67.85 
84.04 
41.11 

48.67 

3.90 
4.63 
8.63 
7.61 
'3.3 

1.17 
1.26 

1.59 
9.57 
3.33 

10.45 
3.15 

3.07 
19.57 

4.55 
48.50 

43.67 

4.75 
4.22 
4.28 
4.72 
6.8 

6.89 
6.50 

4.80 
3.09 
4.91 

1.95 
5.60 

5.59 
8.84 
3.13 
1.33 

3.00 
3.49 
5.23 
3.54 
1.0 

0.40 
0.86 
1.45 
0.60 
0.5 

0.75 
0.76 
0.97 
0.90 
0.2 

Mare 

Ass 

1.84 
1.32               0.34 

0.30 
0.46 

Mule 

Bitch 

Cat 

1.64 
6.10               5.05 
3.12               5.96 

0.38 
0.73 
0.58 

Rabbit 

Llama 

15.54 
3.00              0.90 

2.56 
0.80 

Camel 

Elephant 

Sow 

Porpoise 

4.00 

3.09 

7.23 

11.19 

0.77 
0.65 
1.05 
0.57 

Whale 

7.11 

0.46 

1  Dairy  Chemistry,  1899,  323. 
108 


COW'S  MILK  109 

For  practical  purposes  the  milk  of  the  cow  is  the  only  one  which  can 
generally  be  made  use  of  in  civilized  countries,  and  any  greater  nearness 
in  composition  of  other  milks  to  human  milk  is  of  no  special  advantage, 
since  all  require  modification,  as  by  dilution  or  the  addition  of  sugar, 
cream,  water,  etc.,  or  in  other  ways,  before  they  should  be  used. 

Goat's  Milk.^ — -The  milk  of  the  goat  may  sometimes  be  advan- 
tageously employed  when  that  of  a  cow  is  not  obtainable.  It  is  sufficiently 
similar  to  cow's  milk  to  permit  of  it  being  modified  in  the  same  way. 
It  is  supposed  to  be  superior  in  that  the  goat  is  comparatively  free  from 
tuberculosis;  but  the  casein  coagulates  very  firmly,  and  the  milk  ac- 
quires the  unpleasant  odor  of  the  animal  unless  great  precautions  are 
taken.  It  is  claimed  to  contain  a  greater  percentage  of  iron  than  is 
present  in  cow's  milk,  and  to  be  more  like  human  milk  in  this  respect 
(McLean).^  It  offers,  however,  no  special  advantage  over  the  milk  of 
the  cow. 

Characteristics  of  Cow's  Milk. — The  color  of  cow's  milk  is  more 
yellowish-white  than  that  of  human  milk.  When  absolutely  fresh  and 
obtained  with  proper  care  it  possesses  an  indefinite,  slightly  sweetish 
taste  and  is  practically  without  odor.  The  specific  gravity  ranges  within 
normal  limits  from  1028  to  1033,  with  an  average  of  1032.  The  reaction 
as  ordinarily  obtained  is  faintly  acid  or  amphoteric  to  litmus.  With 
phenolphthalein  it  is  always  acid,  and  to  a  greater  degree  than  human 
milk.  The  fat-globules  vary  greatly  in  size,  the  larger  ones  decidedly 
predominating.  They  are  less  numerous  than  in  human  milk  and  the 
emulsion  consequently  not  so  fine.  Coagulation  occurs  readily  by  acid 
and  by  rennin,  the  resulting  curd  being  firm  and  tough.  When  a  certain 
degree  of  acidity  is  reached  the  milk  will  coagulate  when  heated.  The 
nature  of  the  process  of  coagulation  by  rennin  has  been  much  discussed. 
According  to  Bosworth  and  Van  Slyke-  the  "casein"  exists  in  milk  in  the 
form  of  a  calcium  caseinate.  In  the  presence  of  rennin  the  molecule 
of  this  salt  is  broken  up  into  two  molecules  of  calcium  paracaseinate. 
This  being  less  soluble  than  the  other,  especially  in  the  presence  of  a 
soluble  calcium  salt,  it  is  precipitated  as  the  curd.  The  addition  of 
lime-water  to  milk  forms  a  basic  calcium  caseinate  which  is  not  acted  upon 
by  rennin,  the  milk  being  alkaline  and  the  coagulation  not  taking  place 
by  this  ferment  in  an  alkaline  medium.  When  citrate  of  soda  is  added  to 
milk,  coagulation  is  likewise  delayed,  or  finally  inhibited  if  sufficient  is 
used,  on  account  of  the  formation  of  a  soluble  calcium-sodium  caseinate. 
Rennin  transforms  this  into  calcium-sodium  paracaseinate  which  is 
soluble.  The  presence  of  acid  favors  the  action  of  rennin,  perhaps  by 
the  formation  of  soluble  calcium  salts  from  the  insoluble  calcium  phos- 
phate present  in  the  milk. 

Effect  of  Heat  on  Milk.— Raising  the  milk  to  a  temperature  of 
50°C.  (122°F.)  produces  a  slight  skin  upon  the  surface,  which  becomes 
greater  if  the  milk  he  boiled.  This  is  due  largely  to  a  partial  coagulation 
and  drying  of  the  casein,  and  fat  also  in  considerable  quantity  is  contained 
in  it.  A  temperatur(^  of  7.^°('.  (1(>7°F.)  i:»artially  precipitates  the  lactal- 
bumin,  and  prolonged  l)oiling  does  this  entirely.  Heating  up  to  or  near 
the  boiling  point  gives  rise  to  the  characteristic  odor  of  boiled  milk, 
partly  by  the  production  of  a  sulphur-compound  from  the  lactalbumiii, 
and  a  brownish  tint  is  developed  by  the  boiling  if  prolonged,  dependent 
upon  the  caramelization  of  the  sugar.     The  cream,  too,  rises  imperfectly 

'  Zeit.  f.  Kinderh.,  ()iit>;.,  1912,  IV,  1<)S. 

2  Amer.  Jour.  Dis.  Child.,  I<tl4,  VII,  20S;  Journ.  of  Biol.  Chcin.,  1918,  XIV,  203. 


no  THE  DISEASES  OF  CHILDREN 

or  not  at  all  in  milk  which  has  been  heated  for  half  an  hour  to  a  tempera- 
ture of  65°C.  (149°F.)  (Rosenau),^  owing  to  the  effect  upon  the  emulsion 
of  the  fat  globules;  and  the  action  of  rennin  is  interfered  with.  Even  at  a 
temperature  of  145°F.  (63°C.)  the  rising  of  the  cream  is  prevented  to 
some  extent.  Among  other  changes  produced  by  heat  are  the  driving  off 
of  the  carbonic  dioxide,  oxygen,  and  nitrogen ;  a  precipitation  of  the  phos- 
phates of  the  alkaline  earths  and  of  part  of  the  citric  acid ;  a  diminution 
in  the  organic  phosphorus,  and  a  destruction  in  large  part  of  the  fer- 
ments, the  alexins  and  the  bactericidal  properties  of  the  milk.  Few  of 
these  changes,  however,  occur  except  by  a  raising  of  the  temperature  to 
over  65°C.  (149°F.)  (Hippius);'-  and  even  the  lactalbumin  is  not  greatly 
affected  at  not  over  this  temperature  (Rupp).^  A  continued  elevation 
to  this  degree  consequently  leaves  the  milk  practically  unchanged  in 
most  respects,  with  the  exception  of  'the  interference  with  the  rising  of 
the  cream,  which  is,  as  stated,  unsatisfactory  and  uncertain.  A  large 
number  of  bacteria  of  different  sorts  are  destroyed  bv  a  temperature 
of  65°C.  or  even  60°C.  (149°F.  or  140°F.),  although  "the  peptonizing 
bacteria  of  the  spore-bearing  class  and  many  acid-producing  germs  are 
more  resistant.     (See  Bacteria  of  Cow's  Milk,  p.  113.) 

Effect  of  Freezing. — Many  varying  statements  have  been  made  as 
regards  the  effect  of  freezing  upon  milk.  It  would  appear  to  produce  a 
separation  of  the  oil-globules,  but  other  action  is  uncertain.  Long- 
continued  freezing  has  been  claimed  to  have  a  verj'  decided  influence 
upon  the  chemical  composition  (Pennington,  et  al.).*  Such  freezing  as 
may  ordinarily  be  encountered  in  the  household  employment  of  milk  does 
not  usually  have  any  harmful  effect  upon  infants  receiving  it,  although 
sometimes  constipation,  vomiting  or  diarrhea  may  be  produced. 

Caloric  Value.^ — This  naturally  varies  greatly  with  the  differences 
in  the  composition  of  cow's  milk.  The  range  of  figures  is  from  614  to 
724  calories  per  Ktre  (581  to  685  cal.  per  qt.).  Heubner^  uses  690  to 
express  the  caloric  value  of  a  litre  of  milk  (653  cal.  per  qt.). 

Examination  of  Cow's  Milk. — There  is  so  little  variation  in  the 
amount  of  protein,  sugar  and  salts  in  mixed  herd-milk  that  for  practical 
purposes  these  may  be  taken  as  fixed  amounts,  and  only  the  specific 
gravity,  the  reaction  and  the  variation  of  the  fat  tested  for,  as  well  as  the 
presence  of  bacteria  and  adulterants.  Variations  in  the  specific  gravity 
may  indicate  that  the  milk  has  been  tampered  with.  The  removal  of 
cream  from  the  milk  increases  the  specific  gravity  and  the  addition  of 
water  lowers  it.  The  reaction  is  tested  by  litmus  paper  in  the  ordinary 
way.     Strongly  alkaline  milk  has  probably  been  adulterated. 

The  amount  of  fat  may  be  roughly  estimated  by  the  use  of  the  cream- 
gauge,  but  only  if  the  test  is  commenced  before  cooling  after  milking  has 
taken  place.  A  larger  cylindrical  gauge  should  be  used  than  for  human 
milk,  and  the  calculation  is  made  on  the  basis  that  the  percentage  of 
cream  which  has  risen  after  6  to  8  hours  divided  by  3  will  give  the  per- 
centage of  fat  present  in  the  milk  (Richmond).^  Cream  rises  more  or 
less  irregularly,  and  the  best  method  for  determining  the  fat  is  the  use 

1  Hygienic  Laboratory  Bull.,  1912,  No.  56,  646. 

2  Jahrb.  f.  Kinderh.,  1905,  LXI,  365. 

3  U.  S.  Dept.  Agricult.  Bull.,  166.  Ref.,  Grimmer,  Monatsschr.  f.  ffinderh.,  Referat., 
1912,  XII,  670. 

^  Journ.  of  Biol.  Chem.,  1908,  IV,  353;  1913,  XVI,  331. 
sLehrb.  d.  Kinderh.,  1911,  I,  51. 
6  Dairy  Chemistry,  1899,  103. 


COW'S  MILK  111 

of  the  Babcock  centrifuge,  or  the  smaller  Leffman-Beam  glass  as  described 
under  Human  Milk  (p.  103).  In  the  testing  of  cream  with  this  it  is 
necessary  to  dilute  5  or  more  times. 

If  it  is  desired  to  make  an  approximate  estimation  of  the  protein 
present,  the  method  of  Van  Slyke  and  Bosworth^  may  be  emploj-ed. 

In  addition  it  is  sometimes  necessary  to  examine  milk  for  the  pres- 
ence of  preservatives,  especially  boric  acid,  salicylic  acid  and  formaldehyde, 
and  to  see  whether  it  has  been  heated.  The  methods  are  not  difficult, 
but  [are  better  described  in  special  contributions  to  this  subject.  (See 
Richmond, 2  Freeman, ^  Douglass,*  Whitefield,^  Winslow,^  and  others.) 
A  microscopical  examination  is  also  required  in  many  instances  for  the 
detection  of  pus. 

Composition  of  Cow's  Milk. — The  milk  of  healthy  cows  may  vary 
widely,  depending  upon  peculiarities  of  the  individual  and  of  the  breed, 
the  character  of  the  food,  the  period  of  lactation,  the  amount  of  milk 
which  has  been  drawn  from  the  udder,  the  time  of  day,  and  other  factors. 
Even  the  mixed  milk  of  a  herd  is  subject  to  changes,  and  different  breeds 
vary  one  from  the  other.  The  variation  is  particularly  evident  in  the 
fat,  that  of  the  other  ingredients,  especially  the  sugar  and  mineral 
matter  being  but  slight.  As  a  result  of  the  conditions  mentioned  the 
published  analyses  of  the  chemical  composition  of  cow's  milk  vary  con- 
siderably.    The  following  table  gives  approximate  average  analysis: 

Table  38. — Average  Composition  of  Cow's  Milk 

Water 86.0-88.0  per  cent. 

Total  Solids 12.0-14.0  per  cent.' 

Fat 3.5-  4.0  per  cent. 

Sugar 4.5  per  cent. 

Protein 3.5-4.0  per  cent. 

Salts 0.7  per  cent. 

Nature  and  Normal  Variation  of  the  Constituents  of  Cow's 
Milk.  (See  also  Human  Milk,  p.  95,  for  fuller  description  of  the 
differences.) 

Fat. — The  fat,  as  stated,  is  by  far  the  most  variable  element.  Per- 
centages run  in  round  numbers  all  the  way  from  2  to  over  6  per  cent, 
in  different  cows  and  from  2.5  to  over  5  per  cent,  in  different  herds 
(Konig).''  The  herd-milk  of  Jersey  and  Guernsey  cattle  is  from  1  to  1.5 
per  cent,  richer  in  fat  than  average  cow's  milk;  while  the  sugar  and  pro- 
tein are  also  somewhat  in  excess.  Holsteins  and  Ayershires  produce 
a  milk  slightly  poorer  than  the  average  in  fat  (Lythgoe).^  The  amount 
of  fat  depends  not  only  upon  the  breed,  but  upon  the  food  given  and  the 
general  treatment  and  health  of  the  animal.  It  much  resembles  in  com- 
position the  fat  of  human  milk,  olein  and  palmatin  predominating;  but 
the  volatile  fatty  acids  are  relatively  more  abundant  and  the  amount 
of  oleic  acid  less  than  in  human  milk.  The  envelope  of  the  fat-globules 
is  similar  to  that  of  human  milk. 

Sugar. — The  sugar  may  range  in  individual  cows  from  3.5  to  5.5 
per  cent,  in  round  numbers,  but  in  mixed  herd-milk  the  variation  is  incon- 

1  New  York  Med.  Jour.,  1909,  XC,  542. 

'  Meii.  lice.  1899,  Jan.  21. 

<  Lancet,  1903.  July  4. 

"Pediatrics,  1900,  Jan.  1. 

•The  Production  and  Handling  of  Clean  Milk,  1909. 

'  Cheniio  dcr  nicnschlichon  Nalirungsu.  Clenusniittcl,  1903,  1,  119;   130. 

8  Journ.   Indust.  Kng.  Chein.,   1914,  VI,  899. 


112  THE  DISEASES  OF  CHILDREN 

siderable.  The  nature  of  the  food  has  some  influence  upon  it.  The 
sugar  is  lactose  and  generally  believed  to  be  identical  with  or  closely 
alUed  to  that  of  human  milk. 

Protein. — The  protein  may  range  from  2.5  to  4.5  per  cent.  (Konig) 
in  different  healthy  cows,  but  in  mixed  herd-milk  is  fairly  uniform, 
the  variation  being  not  over  0.5  per  cent.  The  percentage  of  4,  for- 
merl}^  commonly  accepted,  is  generally  not  equalled.  That  of  3.50  more 
fairly  represents  the  standard.  The  protein  consists  of  casein,  lactal- 
bumin,  and  small  amounts  of  lactoglobulin,  as  in  human  milk  but  in 
different  proportions.  The  results  obtained  by  investigators  vary,  Leh- 
mann^  giving  the  ratio  of  the  casein  to  the  lactalbumin  (with  lacto- 
globulin) as  10:1  (casein  3  per  cent.,  albumin  0.3  per  cent.);  Richmond^ 
as  7.5:1  (casein  3  per  cent.,  albumin  0.4  per  cent.);  Schlossmann^  as 
6:1  (casein  3.19  per  cent.,  albumin  0.53  per  cent.);  Konig*  as  5.5:1 
(casein  2.88  per  cent.,  albumin  0.51  per  cent.);  Van  Slyke^  as  about 
4:1  (casein  2.48  per  cent.,  albumin  0.66  per  cent.)  and  White  and  Ladd^ 
as  3:1  (casein  2.94  per  cent.,  albumin  0.9  per  cent.).  The  casein  coagu- 
lates more  readily  by  acids  and  by  rennin  than  does  that  of  human  milk, 
very  possibly  differs  chemically  from  it,  and  certainly  does  so  biologically. 
(See  pp.  96  and  109.) 

Mineral  Matter. — The  mineral  matter  of  cow's  milk  varies  according 
to  different  analyses,  and  is  influenced  to  some  extent  by  the  food.  The 
analysis  of  Soldner  is  compared  in  the  following  table  with  that  of  Bunge 
for  human  milk,  showing  the  contrasts  of  the  relative  percentages.  The 
figures  are  those  quoted  by  Hammarsten.^ 

Table  39. — Percentages  of  Mineral  Matter  of  Cow's  Milk  and  op  Human 

Milk 


Cow's  milk, 
Soldner 

Human  milk, 
Bunge 

Potassium  oxide 

0.172 

0.051 

0.198 

0.02 

0.000358 

0.182 

0.098 

0.0703 

Sodium  oxide 

0.0257 

Calcium  oxide 

0.0343 

Magnesium  oxide 

Ferric  oxide 

0.0065 
0.0006 

Phosphoric  oxide 

Chlorine 

0 . 0469 
0.0445 

The  mineral  matter  of  cow's  milk  differs  from  that  of  human  milk  chiefly 
in  the  much  larger  total  amount  present,  in  the  greater  proportion  of  phos- 
phorus and  of  lime,  potash,  and  magnesia,  and  the  smaller  quantity 
of  iron.  Part  of  the  lime  is  combined  with  the  casein;  the  rest  is  united 
with  phosphoric  acid  to  form  phosphates  which  hold  the  casein  in  sus- 
pension in  the  milk. 

Ferments,  Extractive  Matter,  Etc.^ — Cow's  milk  differs  further  from 
human  milk  in  the  presence  in  it  of  a  much  larger  percentage  of  citric  acid 
(cow's  milk  0.2  per  cent.;  human  milk  0.05)  and  a  much  smaller  amount 

1  Arch.  f.  d.  gesammte  Physiol.,  1894,  LVI,  577. 

2  Dairy  Chemistry,  1899,  120. 

3  Zeitsch.  f.  phys.  Chem.,  1896,  XXII,  211. 
*  Loc.  cit.,  153. 

^  Journ.  Amer.  Chem.  Soc,  1893,  605. 
«  Phila.  Med.  Journ.,  1901,  Feb.  2. 
"  Phys.  Chem.,  1904,  455;  460. 
8  Bunge,  Zeit.  f.  Biol.,  1874,  X,  309. 


COW'S  MILK  113 

of  lecithin  and  of  nucleone.  A  number  of  ferments  characteristic  of 
human  milk  are,  however,  absent  from  that  of  the  cow.      (See  p.  98.) 

Bacteria  in  Cow's  Milk. — All  cow's  milk,  as  ordinarily  supplied, 
contains  numerous  bacteria.  Even  when  first  drawn  from  the  udder  this 
is  the  case,  although  it  is  true  that  by  far  the  greatest  number  of  bacteria 
are  found  in  the  first  part  of  the  milk,  the  latter  portion  being  nearly 
free.  In  addition  to  the  germs  within  the  udder,  direct  contamination 
of  the  milk  occurs  through  the  dust  of  the  stable,  dust  from  the  cow's 
udder  and  belly,  contaminating  cow-manure,  the  hands  of  the  milker  and 
the  like;  and,  inasmuch  as  milk  forms  one  of  the  best  culture  media,  the 
Qiultiplication  of  these  is  extremely  rapid  and  the  number  of  varieties 
great.  Park  and  Holt^  isolated  and  studied  239  species.  The  average 
market-milk  contains  from  2,000,000  to  even  10,000,000  or  more  bac- 
teria to  the  c.c.  (Bergey)  f  a  number  often  greater  than  is  found  in  the 
sewage  of  our  large  cities  (Rosenau).^  The  milk  produced  in  dairies 
managed  with  sufficient  care  need  never  contain  more  than  10,000  to  the 
c.c,  while  an  average  of  from  2000  to  2500  is  [perfectly  possible.  The 
varieties  which  may  be  present  are  very  numerous,  depending  upon  the 
surrounding  sources  of  contamination.  According  to  Bergey  those 
derived  from  the  udder  are  forms  of  staphylococcus  and  streptococcus 
and  the  pseudodiphtheria  bacillus.  Those  entering  in  other  ways  may 
be  classified  into  non-pathogenic  and  pathogenic. 

Of  the  non-pathogenic  the  most  frequent  are  the  lactic  acid-producing 
bacteria,  developing  lactic  acid  by  acting  upon  the  sugar.  Prominent 
among  these  are  the  streptococcus  lacticus,  the  bacillus  lactis  acidi  and, 
less  frequently,  the  bacillus  lactis  aerogenes.  These  germs  enter  the  milk 
during  milking  or  afterward,  at  the  same  time  with  others,  some  of  which 
are  often  displaced  by  the  production  of  an  acidity  which  is  unsuited  to 
their  growth.  A  second  class  is  the  butyric  acid  group,  breaking  up  the 
sugar  and  fat  and  producing  butyric  acid.  A  third  group  is  composed  of  the 
proteolj^tic  bacteria  which,  usually  after  coagulating  the  milk,  may  cause 
a  breaking  up  of  the  protein.  Many  of  these  are  also  capable  of  pr.-duc- 
ing  lactic  acid,  as  for  instance  the  bacillus  coli,  which  is  the  one  of  this 
group  most  commonly  present.  The  bacillus  proteus,  bacillus  alkaligenes 
and  certain  other  germs  belong  to  the  proteolytic  class.  Numerous  other 
organisms  may  be  present,  among  them  pyogenic  germs  derived  from  a 
diseased  udder,  bacteria  giving  rise  to  various  discolorations  of  the  milk, 
or  others  which  give  it  a  bitter  or  other  unpleasant  taste.  To  a  certain 
extent  the  lactic-acid  germs  may  not  be  harmful  if  in  small  amount, 
since  the  acid  produced  serves  to  check  the  growth  within  the  intestine 
of  the  putrefactive  bacteria. 

A  large  variety  of  pathogenic  germs  has  been  found  at  times  in  milk, 
and  epidemics  have  repeatedly  been  traced  to  this  source.  Kober^  collected 
330  outbreaks  of  infectious  diseases  traceable  to  the  milk-supply.  Infec- 
tion through  milk  is  true  especially  of  typhoid  fever,  scarlet  fever  and 
diphtheria.  Epidemics  of  septic  sore  throat  have  been  produced  in  the 
same  way.  Tubercle  bacilli  of  the  bovine  type  may  also  be  found  in 
cow's  milk  if  the  udder  is  tuberculous,  although  they  occasional!}^  occur 
even  when  it  is  healthy,  in  this  case  the  germs  entering  the  milk  after 
milking.     The  human  type  of  tubercle  bacillus  is  probably  the    more 

iMed.  News,  190:5,  LXXXIII,  10(j(). 

2  Univ.  of  Poniiii.  Alcd.  Bull.,  1<»04,  Julv-Augu.st. 

3  Hygienic  Lab.  liuU.,  1912,  No.  5(5,  429. 
••  Amer.  Jour.  Mud.  Sci.,  1901,  Mav. 


114  THE  DISEASES  OF  CHILDREN 

frequent  in  cow's  milk,  entering  it  from  the  dust  of  the  air,  the  hands  of 
a  tuberculous  milker,  or  in  other  ways.  Among  other  pathogenic  germs 
occasionally  occurring  in  milk,  and  in  some  instances  producing  disease 
in  infants  and  children,  are  those  of  cholera,  dysentery,  and  anthrax. 

The  number  of  bacteria  in  cream  is  greater  than  in  milk,  even  when  this 
is  obtained  by  centrifugating  and  with  all  precautions  against  contami- 
nation. Nevertheless  the  experience  of  the  Milk-Commission  of  the 
Philadelphia  Pediatric  Society^  has  demonstrated  that  a  standard  of 
25,000  germs  to  the  c.c.  of  centrifugated  cream  is  not  too  rigorous. 
When  cream  is  obtained  by  the  gravity  process  the  number  of  bacteria 
is  decidedly  increased.  In  comparing  the  different  layers  of  top  milk, 
the  greatest  number  of  bacteria  are  found  near  the  top. 

By  the  heating  of  the  milk  many  of  the  germs  can  be  destroyed. 
Many  of  the  forms  of  lactic-acid-producing  bacteria  are  destroyed  at  a 
temperature  of  60°C.  (140°F.)  as  are  most  of  the  non-spore-bearing  patho- 
genic germs.  The  tubercle  bacillus  is  resistant,  but  will  yield  to  a  tem- 
perature of  155°F.  (68.3°C.)  continued  for  30  minutes.  Rosenau^ 
found  it  no  longer  infectious  when  heated  to  60°C.  (140°F.)  for  2  minutes. 
The  butjTic-acid  bacilli  and  the  spore-bearing  proteolytic  germs  require 
a  higher  temperature,  and  even  that  of  boiling  does  not  destroy  the  spores. 
Consequently  it  has  been  believed  that  the  temperatures  usually  em- 
ployed for  pasteurizing  milk,  which  destroy  the  lactic  acid  bacteria,  give  a 
fuller  opportunity  for  the  subsequent  growth  of  the  dangerous  proteo- 
lytic germs,  because  there  was  no  later  development  of  acidity  to  check 
their  growth,  and  no  warning  of  danger  by  the  milk  turning  sour;  and  that 
especial  care  was  necessary  to  prevent  such  a  growth  in  milk  which  had 
been  heated  in  this  way.  It  has  been  shown,  however,  by  Ayers  and  John- 
son^ that  not  all  of  the  germs  producing  lactic  acid  are  killed  at  a  tempera- 
ture less  than  168°F.  (75.5°C.),  and  that  consequently  there  is  no  special 
opportunity  given  for  the  development  of  the  proteolytic  bacteria.  In 
fact,  the  majority  of  both  the  acid-producing  and  the  proteolytic  germs 
are  destroyed  at  this  temperature,  and  the  subsequent  development  of 
both  sorts  occurs  in  heated  milk  with  the  same  degree  and  with  the  same 
relationship  as  in  raw  milk.  It  has  been  recommended  by  Budde*  to 
add  small  amounts  of  hydrogen  peroxide  to  the  milk,  and  then  to  heat 
this  to  from  50  to  52°C.  (122  to  125.6°F.),  the  object  being  to  destroy 
the  bacteria  more  completely.  It  is  not  certain  that  the  process  is  as 
entirely  harmless  as  claimed. 

Pus  in  Milk. — All  cow's  milk  shows  under  the  microscope  a  certain 
number  of  leucocytes.  As  a  result  of  the  study  of  a  large  number  of 
cows,  Bergey^  and  Stokes^  concluded  that  the  presence  of  more  than  10 
leucocytes  per  field  of  a  ^{2  emersion  lens,  obtained  by  centrifuging  10 
c.c.  (0.338  fl.oz.)  of  milk,  constitutes  pus,  especially  when  the  cells  are 
grouped  in  small  masses  and  accompanied  by  chains  of  streptococci. 
There  is,  however,  a  very  great  range  in  the  number  of  cells  found  in 
milk  from  healthj'  cattle,  and  the  determination  of  the  presence  of  pus 
by  numbers  alone  is  unsatisfactory  (Lewis).'' 

1  Arch,  of  Ped.,  1904,  XXI,  April. 

2  Hyg.  Lab.  Bull.,  1912,  No.  56,  684. 

3  Bull.  126,  Dept.  of  Agriculture,  Bureau  of  Animal  Industry. 

*  Milchzeitung,    1903,    No.   44,   690.     Ref.   Kastle  and   Roberts,   Hygienic  Lab. 
Bull.,  1912,  No.  56,  385. 

5  Dept.  of  Agric.  of  Penna.,  Bulletin  No.  125. 

8  .Arm.  Rep.  Health  Dept.  of  Baltimore,  1898.     Ref.  Bergey. 

7  Amer.  Jour.  Dis.  Child.,  1913,  VI,  225. 


COW'S  MILK 


115 


Cream. — Cream  is  to  all  intents  merely  a  super-fatted  milk,  and, 
strictly  speaking,  any  milk  containing  more  than  4  per  cent,  of  fat  should 
be  called  cream.  It  is  true  that  as  the  percentages  of  fat  increase,  those 
of  sugar  and  of  mineral  matter  diminish  slightly.  Regarding  the  protein 
there  has  been  some  difference  of  opinion.  Wentworth^  maintained  that 
the  amount  of  protein  is  greater  in  cream  than  in  milk.  Adriance,^  on 
the  other  hand,  and  Richmond^  claim  that  the  percentage  decreases  as 
that  of  fat  increases,  and  this  is  the  generally  accepted  view.  There  is 
considerable  discrepancy  in  the  statements  made  regarding  the  degree 
of  diminution  in  the  percentages  of  protein  and  sugar  with  increasing 
strength  of  the  cream  in  fat.  The  following  table  represents  approximate 
averages   based  upon  the  figures  given  by  a  number  of  investigators: 

T.\BLE  40. — Percentages  of  Fat,  Sugar  and  Protein  in  Creams  of  Different 

Strengths 


Per  cent,  cream 

Fat 

Carbohydrate 

Protein 

32 

32 

3.40 

2.5 

20 

20 

3.90 

2.9 

16 

16 

4.20 

3.05 

12 

12 

4.30 

3.20 

10 

10 

4.40 

3.30 

7 

1 

4,45 

3.40 

In  the  proportions  to  which  the  cream  ordinarily  employed  must  be  diluted 
to  obtain  a  sufficiently  small  amount  of  fat,  the  variation  of  the  percent- 
ages of  the  other  solids  is  immaterial  and  may  be  disregarded.  Cream 
is  obtained  either  by  skimming  or  dipping,  in  which  case  it  is  called  "grav- 
ity cream,"  or  by  the  use  of  the  "separator"  and  then  called  "cen- 
trifugated"  or  "separator"  cream.  Practically  all  the  cream  sold  on  the 
market  is  separator  cream.  By  this  process  it  may  be  made  of  almost 
any  strength  desired  up  to  30  per  cent,  or  even  40  per  cent,  or  more  of 
fat,  by  regulating  the  speed  of  the  machine.  The  centrifugated  cream  has 
the  great  advantage  that  it  can  be  prepared  almost  as  soon  as  the  milk 
is  obtained  from  the  cow  and  is  consequently  much  freer  from  bacterial 
growth.  A  disadvantage  claimed  is  that  the  centrifugal  force  breaks  up 
the  emulsion  and  is  harmful  to  the  infant.  I  have  never  witnessed  any 
injury  from  this  source,  and  the  careful  experiments  of  White  and  Ladd* 
indicate  that  no  difference  exists  between  mixtures  made  from  gravity 
cream  and  those  from  centrifugated  cream,  and  that  the  separation  of 
visible  globules  of  fat  sometimes  seen  in  bottles  prepared  for  infant-feed- 
ing may  occur  with  either  and  is  due  to  other  causes,  especially  the  com- 
bined influence  of  heat  and  the  shaking  during  transportation. 

Top=milk. — This  is  the  term  applied  to  any  number  of  the  upper 
ounces  of  the  milk  in  a  milk-jar  after  having  stood  a  number  of  hours. 
Strictly  speaking  top-milk  is  cream,  of  a  strength  varying  with  the  number 
of  ounces  of  milk  which  is  removed  from  the  jar.  As,  however  the  laity 
persist  in  regarding  as  cream  only  the  part  which  has  separated  with  a 
distinct  line  of  demarcation  from  the  milk  below,  and  as  not  infrequently 
it  is  desirable  to  remove  more  than  this,  the  employment  of  the  title 
"top-milk"  is  preferable.     It  designates  the  amount  of  milk  removed, 

'  Boston  Med.  and  Surg.  .Journ.,  1902,  CXLVI,  683;  1903,  CXLVII,  5. 

2  Arch,  of  Pod.,  1900,  May;  1904,  Jan. 

3  Dairy  Chemistry,  1899,  215. 

*  Phila.  Med.  Journ.,  1901,  Feb.  2. 


116 


THE  DISEASES  OF  CHILDREN 


whether  only  1  oz.  or  31  oz.  from  the  quart-jar  of  milk.  Even  with 
the  precaution  in  the  use  of  terms,  and  in  spite  of  directions  which 
seem  explicit,  mothers  frequently  persist  in  removing  from  the  jar 
only  the  number  of  ounces  which  they  require  instead  of  the  number 
ordered  by  the  physician.  It  is  manifest  that  the  strength  of  the  top- 
milk  in  fat  is  in  inverse  proportion  to  the  number  of  ounces  removed,  and 
that  a  very  decided  difference  in  the  milk-mixture  results  if,  for  instance, 
the  top  2  oz.  are  taken  instead  of  2  oz.  from  the  top  8  or  more  of 
the  quart  after  removing  all  of  this. 

To  obtain  top-milk,  a  quart  of  milk,  as  soon  after  milking  as  possible, 
is  strained  into  one  of  the  ordinary  quart  milk-bottles,  closed,  cooled,  and 
then  kept  on  ice  or  in  ice-water  for  6  hours  or  longer.     In  dairy  milk 
delivered  in  jars  the  cream  has  already  risen,  and  there  is  no  need  for  the 
bottles  to  stand  longer  before  removing  the  top-milk,  if  the 
cream-layer  is  sharply  defined.     To  obtain  the  top-milk  one 
may  employ  syphoning,  pouring,  or  dipping.     With  the  for- 
mer a  glass  tube  bent  into  the  form  of  a  syphon  is  filled  with 
sterile  water,  the  long  end  of  this  is  kept  closed  with  the  finger, 
and  the  short  end  then  inserted  carefully  into  the  jar  until 
it  reaches  the  bottom.     The  finger  is  now  removed,  the  water 
allowed  to  flow  out  and  the  milk  which  follows  received  in  a 
graduated  vessel,  the  "top  milk"  meanwhile  sinking  slowly 
toward  the  bottom  of  the  jar.     When  the  desired  number  of 
ounces  remain   in   the  jar,  as  determined  by  observing  how 
man}^  have  escaped,  the  syphon  is  removed.     Great  care  must 
always  be  taken  that  the  jar,  syphon,  and  other  vessels  are 
scrupulously  clean.     Sucking  the  water  through  the  syphon  by 
the  mouth,  in  order  to  start  the  flow  is,  of  course,  out  of  the 
question.     A  much  better  and  easier  method  is  the  employ- 
ment of  the  dipper  devised  by  Chapin^  and  holding  1  oz.  of 
milk^  (Fig.  20).     In  employing  it  enough  of  the   top-milk  is 
first  skimmed  off  with  a  teaspoon  and  placed  in  the  dipper  to 
allow  using  the  instrument  without  causing  the  milk  to  over- 
flow.    As  many  ounces  are  then  dipped  off  as  are  required. 
By  letting  down  the  dipper  carefully  and  slowly  into  the  milk 
the  top  layer  is  disturbed  practically  not  at  all.     A  modifica- 
tion of  the  dipper  has  a  displaceable  bottom  which  allows  of 
the  instrument  being  pushed  into  the  jar  without  danger  of 
causing  an  overflow.     The  original  device  is,  however,  prefer- 
able in  many  respects. 
Still  another  method  consists  in  pouring  oS  carefully  the  number 
of  ounces  of  top-milk  desired.     This  has  been  shown  by  Townsend^ 
to  give  a  top-milk  with  a  percentage  somewhat  less  than  that  obtained 
by  the  other  methods.     As  it  involves  a  different  calculation  it  is  not  to 
be  recommended. 

The  great  advantage  of  top-milk  is  its  economy  and  its  convenience 
when  separator  cream  of  known  strength  in  fat  cannot  be  obtained.  Its 
disadvantages  are  that  it  contains  a  greater  number  of  bacteria,  and  that 
the  fat-percentages  in  it  are  subject  to  decided  variation,  investigators 
differing  somewhat  in  opinion  regarding  this.     The  strength  undoubtedly 

1  New  York  Med.  Journ.,  1899,  Nov.  4. 

^  This  dipper  can  be  purchased  through  druggists,  or  from  the  Cereo  Co.,  Tappan, 
N.  Y. 

3  Boston  Med.  and  Surg.  Journ.,  1903,  CXLVIII,  412. 


COW'S  MILK  117 

varies  with  different  milks,  those  rich  in  fat,  such  as  Jersey,  giving  a  higher 
fat-percentage  in  a  definite  number  of  ounces  of  top-milk.  Due  allowance 
must  be  made  for  this.  Thus,  if  a  milk  containing  5  per  cent,  of  fat  is 
employed,  the  removal  of  the  upper  2  oz.  of  the  quart  after  standing 
reduces  the  fat  to  4  per  cent.  Further  removal  by  dipping  may  now 
be  done,  taking  the  number  of  ounces  which  would  have  been  used  had 
the  milk  originally  been  of  4  per  cent,  fat-strength.  That  is  to  say, 
the  "upper  8  oz.,"  for  instance,  would  mean  the  upper  8  of  the  30 
oz.  remaining  in  the  jar  after  the  top  2  oz.  had  been  removed.  The 
results  of  a  series  of  unpublished  examinations  of  the  fat-strength 
of  top-milk  made  by  Dr.  Chas.  A.  Fife,  combined  with  a  number  of 
estimations  published  by  others  have  led  me  to  the  adoption  of  the  top- 
milk  strengths  which  will  be  referred  to  later  under  Calculation  of  "Milk 
Formulae.  (See  p.  139.)  These  give  results  sufficiently  accurate  for 
practical  purposes. 

Skimmed  Milk,  Bottom  Milk,  Fat=free  Milk. — ^The  milk  remain- 
ing after  any  of  the  cream  has  been  removed  by  skimming  or  by 
dipping  off  the  cream-laj^er  is  denominated  skimmed  milk  or  bottom  milk. 
Its  percentages  of  sugar  and  of  protein  are  slightly  higher  than,  but  for 
practical  purposes  the  same  as,  those  of  whole  milk.  If  2  oz.  of  the  top 
is  removed,  the  fat-strength  equals  3  per  cent. ;  if  all  the  milk  below  the 
cream-layer  is  used  the  fat-strength  is  about  1  per  cent.  If  all  but  the 
lower  quarter  of  the  jar  is  taken  away  the  percentage  is  less,  frequently 
then  being  from  0.2  to  0.5  per  cent.,  and  the  milk  may  be  considered  as 
fat-free.  (See  p.  139.)  Actual  fat-free  milk,  however,  can  be  obtained 
only  by  the  use  of  the  separator.  A  comparison  of  the  relative  strengths 
of  the  different  elements  in  whole  milk,  skimmed  milk  and  fat-free  milk, 
as  given  by  Morse  and  Talbot,^  may  be  seen  in  the  following  table: 

Table  41. — Comparison  of  Whole  Milk,  Skimmed  Milk  and  Fat-free  Milk 


Fat 

Sugar 

Protein 

Whole  milk 

4  0 

4.5 
5.0 

5,0 

3.50 

Skimmed  milk 

1.0 

3 .  55 

Fat-free  milk 

0  25 

3  05 

Requirements  in  Good  Milk. — There  are  certain  requisites  which 
must  be  insisted  upon  in  order  to  make  cow's  milk  a  safe  and  satisfactory 
food.  First  of  all  it  must  be  clean.  The  centrifugating  process  applied 
to  ordinary  cow's  milk  obtained  without  sufficient  care  shows  that  this 
is  far  from  being  true  of  it.  Cleanliness  with  regard  to  contamination  b.y 
bacteria  is  important.  There  should  be  an  absence  of  pathogenic  germs 
and  but  a  small  number  of  those  of  other  sorts.  The  milk  should  be 
tampered  with  in  no  way,  as  by  the  addition  of  such  preservatives  as 
boric  acid  and  formaldehyde,  the  removal  of  any  of  the  cream,  or  the 
addition  of  water.  Much  of  that  furnished  is  very  decidedly  over  24 
hours  old  before  it  is  used.  If  it  has  been  pasteurized  it  should  be  dis- 
tinctly stated  on  the  bottle  that  this  has  been  done.  An  unusually  low 
bacterial  count  in  milk  not  known  to  have  been  produced  with  especial 
care  suggests  the  emplo3'mcnt  either  of  chemical  preservatives  or  of  heal. 
The  milk  should  l)c  kept  constantly  at  a  temperature  not  over  4o°F. 
(7.2°C.)  from  the  time  it  is  bottled  until  it  is  prcpannl  for  use,  and  tiie 
'  Diseases  of  Nutrition  aiid  Iiil'mit   I'ccdiiifr,  HH."),  217. 


118  THE  DISEASES  OF  CHILDREN 

time  of  transportation  should  be  as  brief  as  possible.  Uniformity  in 
strength  is  necessary,  with  conformity  to  the  analytical  standards  of 
normal  milk.  If  the  cow's  milk  varies  materially  it  is  manifestly  impos- 
sible to  modify  it  in  a  way  which  will  agree  with  the  child  to  whom  it  is 
fed.  If  it  is  from  cows  which  are  ill  its  quality  becomes  impaired,  or 
it  may  become  decidedly  harmful  to  the  infant.  Consequently  mixed 
herd-milk  is  to  be  preferred  to  that  from  a  single  cow,  as  less  liable  to 
exhibit  sudden  alterations  in  strength. 

Dairy  Methods.- — The  best  methods  of  dairy  management  must 
be  followed  to  ensure  the  fulfilling  of  these  requirements  for  good  milk. 
The  cows  should  receive  a  carefully  adjusted  diet  and  be  exercised  daily. 
They  should  not  be  allowed  to  pasture  at  large,  eating  what  they  may 
find.  They  should  not  be  fed  immediately  before  milking  on  account 
of  the  dust  produced  thereby.  The  milk  should  be  from  a  mixed  herd, 
preferably  of  ''grade"  cattle.  Jersey  cattle  produce  a  milk  too  rich 
in  fat;  Holstein  and  Ayreshire  one  rather  poor.  The  stable  must  be 
well  ventilated,  commodious,  dry,  screened,  and  kept  strictly  clean,  and 
the  cows  so  stalled  that  they  cannot  soil  themselves  or  reach  their  udders 
with  their  heads.  They  should  be  cleaned  and  brushed  daily,  but  not 
just  before  milking,  and  the  hair  upon  the  bellies,  udders,  inside  of  the 
thighs,  and  tails  should  be  clipped  short.  The  udders  and  teats  should 
be  washed  with  sterilized  water  before  milking,  and  the  milk-men  should 
dress  in  washable  sterilized  clothing  and  caps,  and  wash  the  hands  before 
the  milking  of  each  cow.  Vessels  of  any  kind  into  which  milk  enters 
must  be  kept  bacteriologically  clean.  The  milk-pails  should  be  of  special 
design  intended  to  prevent  the  ready  entrance  of  dust  from  the  cow's 
belly  or  from  the  air  of  the  room.  Immediately  after  milking  the  milk 
should  be  rapidly  cooled,  strained,  put  in  sterilized  milk-jars  and  sealed. 
The  cows  should  be  in  good  health,  and,  to  insure  this,  frequent  veteri-- 
nary  examinations  must  be  made,  both  of  the  animals  and  of  their 
surroundings,  and  all  those  affected  by  any  disease,  especially  by  a  sup- 
purating affection  of  the  udder  or  by  tuberculosis,  must  be  promptly 
withdrawn.  Jersey  cattle  are  claimed  to  be  particularly  prone  to  tuber- 
culosis in  this  country,  and  all  highly  bred  cows  are,  as  a  rule,  of  less 
vigorous  health  than  "grade"  cattle.  Strict  precautions,  too,  must  be 
taken  against  the  existence  of  any  infectious  disease  among  the  employees 
of  the  dairy  or  their  families,  lest  such  become  communicated  to  infants 
through  the  milk. 

Certified  Milk.^ — The  evident  lack  in  ordinary  dairies  of  the  ful- 
fillment of  any  such  regulations  as  those  just  mentioned,  led  to  the  estab- 
lishment in  various  cities  of  Milk-Commissions,  which  in  1907  associated 
themselves  as  the  American  Association  of  Medical  Milk-Commissions. 
The  requirements  detailed  above  constitute  in  most  respects  a  partial 
abstract  of  the  regulations  adopted  by  the  association.  The  purpose  of 
a  Milk-commission  is  to  prescribe  rules  and  regulations  for  dairies,  with 
which  a  contract  is  to  be  made,  and  to  see  by  inspection  that  the  prescribed 
requirements  and  agreements  are  fulfilled.  Personal  systematic  inspec- 
tion of  the  dairy  is  made  from  time  to  time  by  members  of  the  Commis- 
sion, and  repeated  examinations  of  the  buildings  and  the  cows  conducted 
by  the  Commission's  veterinarian,  and  of  the  milk  by  its  chemists  and 
bacteriologists.  To  dairies  the  product  of  which  fulfills  the  requirements 
a  certificate  is  given  to  that  effect,  and  such  milk  is  properly  called 
"certified  milk."  It  is  hardly  necessary  to  say  that  much  milk  is  adver- 
tised and  sold  by  dealers  as  "certified"  which  in  no  way  belongs  in  this 


GENERAL  PRINCIPLES  OF  SUBSTITUTE  FEEDING 


119 


category,  the  certifying  being  either  a  fiction  or  done  by  those  employed 
by  the  dairy  for  this  purpose. 

Properly  certified  milk  usually  and  rightly  sells  at  an  increased  price, 
since  the  cost  of  its  production  is  necessarily  increased.  With  sufficient 
ordinary  care,  however,  a  great  improvement  in  the  quality  of  ordinary 
market-milk  can  be.  made  without  any  material  increase  in  the  expense. 


GENERAL  PRINCIPLES  OF  SUBSTITUTE  FEEDING 

Comparison  of  Human  and  Bovine  Milk.^ — ^Before  proceeding 
to  the  study  of  the  preparation  of  milk-mixtures,  we  may  conveniently 
place  before  us  in  tabular  form  the  contrasts  between  human  and  bovine 
milk  which  have  already  been  considered.  The  figures  are  approximate 
ones: 

Table  42. — Principal  Contrasts  op  Average  Bovine  and  Human  Milk 


Cow's  milk 


Human  milk 


Specific  gravity 1032 

Color. White. 

Bacteria Always  present. 

Coagulation  by  rennet  and  acid'  Readily  and  produces  firm 

curds. 

Reaction  to  litmus 

Fat 


Sugar 

Total  Protein 

Total  Lactalbumin . 

Total  Casein 

Mineral  matter .... 

Total  Solids 

Water 


Generally  acid. 
4  per    cent.;     containing 
more  volatile  fatty  acids. 


4 . 5  per  cent. 
3 . 5-4  per  cent. 
0.3    per  cent.' 
3.0    per  cent.' 
0.7    per  cent. 

12-14  per  cent. 

86-88  per  cent. 


1030-31 
Bluish-white. 
Practically  none. 
Less  easy  and  produces  soft, 

flocculent  precipitate. 
Alkaline  or  amphoteric. 
3.5-4   per  cent.;  contain- 
ing less  volatile  and  more 
oleic  acid. 

7  per  cent. 
1-1 .50  per  cent. 
0.5    per  cent.' 
1 .2    per  cent.' 
0.2    per  cent. 
12-13  per  cent. 
87-88  per  cent. 


The  figures  for  lactalbumin  and  casein  are  those  of  Lehmann.^  Refer- 
ence to  pp.  96  and  112  shows  the  variation  among  investigators  as  to 
the  relative  proportions  of  these  two  elements.  All  indicate,  however, 
the  relative  increase  in  the  proportion  of  lactalbumin  in  human  milk  as 
compared  with  cow's  milk. 

Modification  of  Milk. — The  object  in  adapting  cow's  milk  to 
infant-feeding  is  to  change  or  modify  it  in  some  way,  since  without  this 
change  it  is  not  tolerated  by  the  majority  of  infants  in  the  1st  year  of 
life.  A  widespread  misconception  exists  among  the  laity  regarding  this. 
By  them  "modified  milk"  is  often  spoken  of  as  though  it  were  some  spe- 
cific sort  of  food.  As  a  matter  of  fact  any  element  taken  from  or  added 
to  milk  modifies  it,  even  the  mere  addition  of  water.  ^Modification  is, 
therefore,  a  wide  term  indicating  any  change  produced  artificially  in  the 
milk.  It  becomes  obvious  from  the  study  of  the  tabular  composition  that 
cow's  milk  in  its  natural  state  is  far  from  suited  to  the  healthy  infant 
during  the  1st  year  of  life.  Simple  dilutions  alter  the  proportions  of  all 
the  solids  uniformly,  and  arc  sufficient  in  some  instances,  wliile  in  others 
other  methods  are  required.  In  brief  the  objects  of  modification  are 
chiefly  to  prevent  the  development  of  bacteria  or  to  reduce  the  number 
already  present;  to  prevent  the  formation  of  the  firm,  large  ronnin  curd; 
to  correct  the  acid  reaction;  to  reduce  the  protein,  and  somolinies  to  lUmin- 

*  Lehmann,  Arch.  f.  d.  gesammte  Physiol.,  1894,  LVI,  577. 


120  THE  DISEASES  OF  CHILDREN 

ish  especialh''  the  casein  by  the  employment  of  whej^;  to  reduce  the  salts; 
and  to  maintain  or  lessen  the  percentage  of  fat,  this  reduction  being 
frequently  necessary  on  account  of  the  large  proportion  of  volatile  fatty 
acids  in  cow's  milk.  Theoreticallj'  the  accomplishment  of  such  changes 
seems  easy.  Practicallj''  it  is  impossible,  no  matter  what  we  do,  to  pro- 
duce a  perfect  imitation  of  human  milk.  This  should  be  recognized  at 
the  outset.  The  differences  in  the  character  of  the  fat  cannot  be  satis- 
factorily altered  by  any  modification;  the  biological  characters  of  the 
casein  are  not  the  same;  the  ferments  are  different.  So,  too,  although  it 
would  appear  at  first  sight  that  the  nearer  the  percentage  of  the  food- 
elements  corresponded  with  those  of  human  milk,  the  better  suited  the 
food  would  be  for  the  infant,  experience  has  taught  that  this  is  far  from 
the  truth;  owing  in  part  to  the  different  ultimate  constitution  of  the 
various  elements,  and  in  part  to  the  individuality  of  the  infant.  No  one 
formula  can  be  expected  to  suit  even  the  healthy  child ;  and  the  problem 
of  adapting  the  requirements  to  the  infant  with  digestive  disturbance  is 
many  times  greater. 

Percentage=feeding. — With  the  growth  of  a  fuller  knowledge  of 
the  composition  of  cow's  milk  came  the  expansion  of  the  principles  of 
what  has  been  called  "Percentage-feeding."  The  percentage-method 
is  not  in  itself  new.  Biedert^  emphasized  its  importance  in  a  general 
way;  and  still  earlier,  in  1858,  Cummings-  gave  a  clear  exposition  of  it. 
There  had  been,  however,  no  special  stress  laid  upon  the  importance  of 
modifying  as  required  the  percentages  of  one  or  another  ingredient  of  the 
milk-mixture,  and  no  method  devised  for  a  ready  accomplishing  of  these 
alterations,  until  the  writings  of  Rotch^  brought  the  matter  into  promi- 
nence. Percentage-feeding  marked  a  great  advance  in  the  scientific 
feeding  of  infants.  Physicians  had  for  years  prescribed  modified  cow's 
milk;  i.e.,  they  had  ordered  a  varying  number  of  ounces  of  milk  diluted 
with  water,  adding,  it  may  be,  cream  and  sugar,  and  changing  these 
modifications  to  suit  the  case.  The  results,  of  course,  were  percentage 
modifications  of  the  cow's  milk  ingredients,  yet  what  these  were  the 
prescriber  usually  did  not  know.  The  method  was  inexact  because  the 
thought  was  in  terms  of  such  composite  articles  as  "milk"  and  "cream;" 
and  to  obtain  accuracy  in  composition  and  in  results  was  impossible 
in  this  way.  In  the  percentage  method  one  thinks  in  definite  percentages 
of  "fat,"  "sugar,"  "protein,"  etc.,  determining  how  much  of  each  the 
individual  infant  requires.  The  percentages  thus  chosen  are  then  trans- 
formed into  terms  of  the  number  of  ounces  of  milk,  water,  cream,  etc., 
required  to  be  equivalent  to  these.  (See  p.  137  et  seq.).  The  great  ad- 
vantages are  increased  accuracy  of  thought  and  the  consequent  better 
results  to  be  expected.  The  problem,  for  instance,  of  how  to  increase  the 
protein  of  a  milk-mixture  without  increasing  the  fat  can  be  solved  only 
by  thinking  in  percentages. 

The  percentage  method  has  suffered  from  much  lack  of  comprehen- 
sion and  from  misstatement.  It  has  been  looked  upon  as  an  innovation, 
considered  comphcated,  and  called  by  European  writers  the  "American 
method."  There  is,  in  fact,  nothing  comphcated  about  it,  and  any  school- 
boy who  has  studied  the  rules  of  proportion,  possesses  all  the  mathematical 
knowledge  required.     As  to  its  newness,  it  is,  as  stated,  not  new.     The 

1  Untersuch.  ii.  d.  chem.  Unterschieden  d.  Menschl-  u.  Kuhmik-h,  Inaug.  Dis- 
sert., Giessen,  1869. 

2  Amer.  Jour.  Med.  Soi.,  1858,  XXXVI,  25.     Food  for  Babies,  1859. 

3  Brit.  Med.  Journ.,  1902,  Sept.  6. 


GENERAL  PRINCIPLES  OF  SUBSTITUTE  FEEDING  121 

only  thing  really  new  in  it  was  the  method  of  thinking,  by  which  the  food- 
mixture  is  built  up  synthetically  from  its  elements  to  attain  the  desired 
chemical  composition.  It  has  nothing  whatever  to  do  with  the  choice 
of  the  food-elements,  and  is  in  no  sense  a  method  of  feeding.  It  merely 
records  with  approximate  accuracy  the  percentage  amount  of  these 
elements  employed,  and  enables  a  change  readily  to  be  made  in  them 
according  to  the  requirements  of  the  case.  Much,  too,  has  been  written 
in  recent  years  regarding  the  superiority  of  the  so-called  "simple  dilution" 
of  milk  over  percentage-feeding.  This  shows  a  total  lack  of  comprehen- 
sion of  the  subject.  There  can  be  no  possible  contrast  or  contradiction 
between  them.  Any  physician  is  entitled  to  use  whole  milk  diluted  with 
water,  and  with  the  adcUtion  of  sugar,  in  any  amount  the  case  requires, 
and  in  fact  such  dilutions  are  all  that  is  needed  in  many  instances.  The 
important  matter  for  scientific  feeding  is  to  realize  the  percentages  of 
fat,  sugar  and  protein  which  are  obtained  in  this  way;  and  such  recogni- 
tion makes  the  method  a  percentage  one;  and  in  any  event  the  proper 
amount  of  sugar  to  be  added  has  to  be  determined  by  a  percentage  calcu- 
lation. The  fact  is  not  to  be  forgotten,  however,  that  the  normal  healthy 
baby  needs  and  can  digest  fat;  and  that  the  invariable  employment  of 
diluted  whole  milk  reduces  this  element  below  the  infant's  capacity 
and  requirements,  and  forces  the  use  of  other  elements  in  excess  to  make 
up  the  caloric  deficiency.  Without  the  knowledge  of  percentage  compo- 
sition no  scientific  infant-feeding  is  possible. 

It  is  to  be  understood  that  the  percentage  method  is  not  supposed  to 
give  absolutely  accurate  statements  of  the  amount  of  the  various  food- 
elements  present.  This  is  not,  however,  a  matter  of  practical  importance. 
It  islnot  so  much  minute  knowledge  of  the  initial  composition  which  is 
desired,  as  the  abihty  to  increase  or  decrease  with  comparative  accuracy 
one  or  more  of  the  ingredients  at  will,  according  to  the  necessities  of  the 
case  and  guided  by  the  knowledge  of  the  mutual  relationsliips  which 
the  elements  bear  to  each  other.  It  is  evident,  too,  that  the  employ- 
ment of  the  "caloric  method,"  to  be  described  in  the  next  section,  is,  in 
the  nature  of  things,  an  impossibility  without  the  knowledge  of  the  per- 
centage composition  of  the  milk-mixture. 

The  "Caloric  Method"  (See  also  p.  52). — This  in  its  origin  was 
simple.  Heubner^  as  a  result  of  careful  experimental  work  upon  healthy 
breast-fed  infants,  came  to  the  conclusion  that  100  calories  per  kilogram 
of  body-weight  of  the  breast-fed  child  should  be  rendered  daily  bj^  the  food 
in  the  first  part  of  the  1st  year,  or  120  calories  in  the  case  of  artificially 
fed  children,  with  a  gradual  progressive  diminution  in  number  during  the 
year.  This  figure  expressive  of  the  division  of  the  total  caloric  need  by 
the  weight  of  the  infant  he  called  the  "Energy-quotient. "  In  avoirdupois 
it  is  expressed  by  45  calories  per  pound  of  body-weight.  Heubner  then 
adopted  a  series  of  different  dilutions,  using  }^,  }2,  or  2^  of  whole  milk 
in  water,  and  merely  added  a  sufficient  percentage  of  sugar  and  starchy 
material  to  make  up  the  calories  to  the  required  normal  amount.  Vari- 
ous later  investigators  have  confirmed  his  views,  although  witli  consider- 
able difference  of  opinion  as  to  the  figures  which  most  accurately  express 
the  energy-quotient;  and  various  other  calculations  have  been  made 
permitting  the  use  of  other  than  these  simple  (Ulutions,  yet  based  upon 
a  calculation  of  the  calories  contained.  The  en(M'gy-(iuotient  at  i)resent 
very  commonly  adopted  for  breast-fed  and  artificially  fed  infants  is  100 
for  the  first  quart (>r  of  the  1st  year,  90  for  the  S(>conil,  80  for  the  third, 
'  Zcit.  f.  (liiit.  u.  physikiil.  TlicraiMc,  HlOl,  V,  13. 


122  THE  DISEASES  OF  CHILDREN 

and  70  for  the  fourth  quarter.  In  avoirdupois  weights  these  would  be 
approximately  equivalent  to  45,  40,  35  and  30  calories,  respectively, 
per  pound  of  body- weight. 

The  method  is  of  great  advantage  in  that  it  enables  one  promptly 
to  determine  whether  or  not  a  normal  infant  may  be  considered  to  be 
under- fed  or  over-fed  as  far  as  calories  go.  It  has,  however,  distinct 
disadvantages,  if  followed  too  imphcitly.  Not  only  is  there,  as  stated, 
a  discrepancy  in  the  definition  of  what  actually  constitutes  the  energy- 
quotient  for  normal  infants,  but  for  premature  and  emaciated  infants  the 
figure  given  by  Heubner  may  be  distinctly  too  low,  inasmuch  as  it  is  based 
upon  the  weight  of  the  child  and  not  upon  its  body-surface  or  body-bulk 
as  it  should  be.  On  the  other  hand,  the  activity  of  the  child  is  to  be 
considered;  one  exhibiting  free  movements  of  the  body,  or  crying  much, 
having  a  greatly  increased  heat-dissipation,  and  requiring,  consequently, 
more  calories;  while  a  marantic  infant  whose  movements  are  sluggish, 
feeble  and  infrequent,  and  whose  life-forces  are  at  a  low  ebb  may  be  suffi- 
ciently nouiished  by  food  containing  distinctly  fewer  calories  than  would 
have  been  expected.  The  difference,  too,  between  the  sleeping  and  the 
waking  state  is  decided.  We  have  no  means  of  knowing,  therefore,  what 
the  energy-quotient  really  is  for  infants  other  than  those  in  health,  and 
it  is  probable  that  the  requirements  vary  with  the  child  (Rowland.)  ^  The 
greatest  disadvantage  of  the  method,  if  followed  strictly  and  not  as  its 
originator  intended,  is  the  tendency  for  the  physician  to  take  too  little 
account  of  the  relative  assimilability  of  the  different  food-elements,  but 
to  regard  it  as  a  matter  of  indifference  which  is  employed,  so  long  as  the 
food  contains  sufficient  calories.  Of  course  in  actual  practice  no  experi- 
enced pediatrist  would  act  according  to  this;  but  the  less  experienced 
physician  may  readily  be  led  into  the  mistake.  It  is  evident  that  a  food 
may  contain  the  requisite  number  of  calories  and  yet  be  constructed  upon 
an  entirely  wrong  basis.  Protein,  for  instance,  might  have  been  left  out 
completely,  and  the  caloric  requirements  still  be  met;  but  on  such  a  food 
life  would  be  impossible.  On  the  other  hand,  the  caloric  requirements 
may  be  supplied  by  fat  in  a  percentage-mixture  of  a  fat-strength  which 
would  cause  active  indigestion  in  the  healthiest  baby.  The  method  is, 
therefore,  like  that  of  percentages,  not  a  method  of  feeding.  It  is  only  one 
of  calculation,  serviceable  in  estimating  whether  or  not  the  food  answers 
the  infant's  caloric  needs.  It  aids  in  no  way  in  determining  how  the  food 
shall  be  composed  in  order  that  these  needs  shall  be  met. 

If  perfectly  understood  there  can  be  no  possible  conflict  between  the 
two  so-called  "methods."  The  percentages  of  the  elements  of  the  food 
should  first  be  selected  according  to  the  digestive  capacity  of  the  infant, 
and  the  caloric  value  of  these  then  calculated  to  determine  whether  the 
energy-requirements  are  fulfilled. 

With  the  accepted  data  that  1  gram  of  fat  furnishes  in  the  economy 
9.3  calories;  and  1  gram  of  protein  and  of  carbohydrate  each  4.1  calories, 
it  is  readily  possible  to  estimate  the  total  number  of  calories  in  a  litre 
of  any  milk-mixture,  if  the  percentage  composition  is  known.  Thus 
supposing  an  infant  is  receiving  a  litre  of  a  food-mixture  containing 
fat,  3  per  cent. ;  sugar,  6  per  cent,  and  protein,  1.5  per  cent:  If  we  multiply 
1000  grams  by  each  of  these  figures  we  obtain  as  present  in  the  food: 

Fat  =  1000  X  0.03  =30  grams 
Sugar  =  1000  X  0.06  =60  grams 
Protein  =  1000  X  0.015  =  15  grams 

lAAer.  .Journ.  Dis.  Child.,  1914,  V,  393. 


GENERAL  PRINCIPLES  OF  SUBSTITUTE  FEEDING  123 

If  now  we  multiply  each  of  these  amounts  by  the  number  of  calories 
which  1  gram  produces,  we  obtain: 

Fat  =  30  X  9.3  =  279.0  calories 

Sugar      =  60  X  4. 1  =  246.0  calories 

Protein  =  15X4.1=    61.5  calories 

Total  in  1  litre  of  food  =  586 . 5  calories 

Since  the  infant  requires  in  its  food  100  calories  per  kilogram  of  its 
body-weight,  we  find  that  586.5  calories  divided  by  100  =  5.865;  i.e. 
the  weight  in  kilograms  of  the  infant  which  should  thrive  upon  this  quan- 
tity of  food,  so  far  as  the  caloric  value  is  concerned. 

When  the  infant  is  fed  and  weighed,  as  is  customary  in  English  speak- 
ing countries,  in  terms  of  ounces,  a  fourth  calculation  is  required  reducing 
the  metric  to  avoirdupois  system.  As  this  is  inconvenient,  it  is  better  to 
make  the  calculations  from  the  beginning  in  English  measures.  A  very 
simple  formula  has  been  calculated  by  Fraley^  which  gives  results  quite 
sufiiciently  accurate  for  practical  purposes.     This  formula  in  brief  is 

(2F +  S -\-P)xmQ  =  C 

or,  in  detail,  twice  the  fat-percentage,  plus  the  sugar-percentage,  plus  the 
protein-percentage,  multiphed  by  one  and  a  quarter  times  the  total  quan- 
tity of  food-mixture  given  in  the  day,  equals  the  total  number  of  calo- 
ries furnished  by  the  day's  food.  Supposing,  for  example,  a  milk-mixture 
contains  fat,  3  per  cent. ;  sugar,  6  per  cent. ;  protein,  2  per  cent. ;  6  bottles  of 
6  oz.  each  administered;  i.e.,  36  oz.  in  the  24  hours.  Substituting  these 
figures  the  formula  will  read  (2X3  +  6  +  2)  X  (1^  X  36)  =  14  X 
45  =  630  calories.  Dividing  this  by  45,  the  number  of  calories  required 
per  pound  of  body-weight,  we  have  resulting  15  pounds.  That  is  to  say, 
the  formula  should  be  sufficient  for  a  child  weighing  15  pounds.  A 
modification  of  the  Fraley  formula  (Holt  and  Howland)^  may  be  use- 
fully employed  in  another  way,  to  estimate  the  caloric  value  of  each 
ounce  of  the  food  used.  In  the  form  of  an  equation  it  reads  as  follows: 
{2F  +  /S  +  P)  X  1.3  =  No.  of  calories  in  an  ounce  of  the  food. 

A  knowledge  of  the  caloric  value  of  milk  and  milk-derivatives,  as 
well  as  of  various  other  articles  of  diet  suitable  for  infants  and  children, 
is  often  of  great  value.  A  list  of  such  equivalents  will  be  found  later 
(p.  175). 

Details  for  iVVilk=modification. — With  the  differences  between 
cow's  milk  and  human  milk  in  view,  as  shown  in  the  table  already  given 
(p.  119),  we  may  take  up  the  method  to  be  employed  to  eUminate  these 
as  far  as  is  necessary. 

Altering  the  Reaction. — This  is  best  done  by  the  addition  of  Hnie- 
water.  An  amount  equal  to  at  least  5  per  cent,  of  the  total  food,  i.e., 
^i  oz.  to  each  10  oz.,  will  be  needed  to  make  the  alkalinity  of  a  cow's 
milk-mixture  equal  approximately  that  of  human  milk.  If  for  any 
reason  lime-water  is  not  employed,  bicarbonate  of  soda  may  be  sub- 
stituted, 1  grain  of  this  being  equivalent  in  alkalinity  to  1  oz.  of 
Hme-water.  The  action  of  lime-water  or  other  alkali  after  its  inges- 
tion is  not  thoroughly  understood,  and  it  is  questionable  whether  in  the 
present  state  of  our  knowledge  any  alkali  is  necessary  or  advisable.  The 
lime-water,  it  is  true,  neutralizes  the  acidity  of  the  cow's  milk,  as  also  later 
the  hydrochloric  acid  secreted  in  the  stomach,  and  delays  or  prevents  the 

>  Arch,  of  Ped.,  1912,  XXIX,  123. 
2  Diseases  of  Children,  1910,  181. 


124  THE  DISEASES  OF  CHILDREN 

formation  of  large,  tough  protein  curds  (see  p.  109);  and  it  has  been  be- 
lieved that  in  this  way  it  favors  the  more  rapid  emptying  of  the  stomach. 
To  accomplish  any  inhibition  of  coagulation  within  the  organ  it  must, 
however,  be  given  in  much  larger  amount  than  is  ordinarily  employed 
(25  to  50  per  cent.,  Morse  and  Talbot),^  and  the  increasing  of  alkahnity 
in  this  way  would  result,  according  to  Cowie  and  Lyon,-  in  delaying  the 
opening  of  the  pylorus  and  the  exit  of  the  milk  through  it.  Clark^ 
maintains  that  the  addition  of  lime-water  to  the  food  in  reality  stimu- 
lates the  stomach  to  an  increased  secretion  of  hydrochloric  acid.  It  is 
evident,  therefore,  that  our  knowledge  of  the  action  of  lime-water  is  far 
from  complete.  It  is  a  mistaken  idea  that  lime  water  should  be  added 
in  order  to  supply  mineral  matter  for  the  proper  development  of  the 
osseous  tissues.     This  is  entirely  unnecessary. 

Preventing  the  Formation  of  Firm  Casein  Coagula. — This  is  some- 
times necessary,  and  is  to  be  accomphshed  in  various  ways.  The  use  of 
alkalies,  as  stated,  aids  in  the  matter.  Citrate  of  soda  has  been  much 
employed  to  prevent  the  coagulation,  giving  generally  about  1  grain 
for  every  ounce  of  milk.  Boiling  the  milk  is  another  efficacious  method 
(p.  109);  or  the  total  amount  of  casein  in  the  mixture  may  be  reduced, 
and  the  deficiency  of  protein  made  good  by  the  giving  of  lactalbumin  in 
the  form  of  whey  (see  p.  145).  The  addition  of  a  cereal  diluent  in- 
stead of  water  mechanically  prevents  the  formation  of  tough  coagula, 
acting,  it  is  believed,  as  a  protective  colloid.  From  0.60  to  1.20  per  cent, 
of  starch  should  be  employed.  (See  p.  152.)  Peptonizing  the  milk  may  be 
used  in  some  cases  (p.  146),  or  buttermilk  given  (p.  147),  since  the  casein 
in  this  is  not  affected  by  rennet.  In  casein-milk  also  (p.  148)  the  casein 
is  in  a  form  in  which  large,  tough  curds  cannot  develop. 

Altering  the  Proportions  of  the  Milk-elements. — Should  it  be  the 
intention  to  alter  the  composition  of  cow's  milk  to  make  it  more  closely 
resemble  human  milk^ — a  procedure  not  always  to  be  desired — the  reduc- 
tion of  the  percentage  of  the  proteins  is  a  simple  matter  if  we  treat  these 
bodies  as  a  unit.  It  is  accomplished  by  merely  adding  to  the  milk  some 
attenuant,  generally  water,  in  the  proportion  of  2  or  3  times  its  volume.  If, 
however,  we  have  regard  to  the  composite  nature  of  the  protein-element, 
and  wish  to  approach  the  composition  of  human  milk  more  closely  than 
simple  dilution  accomplishes,  it  is  necessary  to  reduce  the  percentage  of 
casein  while  leaving  the  lactalbumin  unaffected.  This  can  be  clone  by  the 
use  of  whey-mixtures,  since  the  casein  has  been  removed  from  them  by 
the  action  of  rennin.  The  employment  of  whey  for  this  purpose  will  be 
described  later  (p.  145). 

Disregarding  the  difference  in  the  proteins,  and  with  the  intention  of 
simulating  human  milk  in  other  respects — a  procedure,  as  stated,  not 
always  to  be  desired — it  will  be  noticed  in  consulting  the  table  on  p. 
119  that  in  diluting  cow's  milk  with  2  or  3  parts  of  water  the  protein-per- 
centage sought  for  is  reached,  and  that  the  salts  likewise  are  reduced  suffi- 
ciently for  all  practical  purposes.  Simultaneously,  however,  the  amount 
of  fat  will  be  made  decidedly  below  the  percentage  present  in  human 
milk,  and  that  of  sugar  still  more  so.  The  obvious  remedy  is  to  add 
sugar  and  fat  to  the  mixture.  The  percentage  of  sugar  is  increased 
merely  by  adding  enough  to  bring  the  figure  up  to  the  required  amount. 
The  percentage  of  fat  may  be  maintained  either  by  diluting  a  top-milk 

1  Diseases  of  Nutrition  and  Infant  Feeding,  1915,  204. 

2Amer.  Jour.  Dis.  Child.,  1911,  II,  2.52. 

3  Amer.  Jour.  Med.  Sci.,  1909,  CXXXVII,  872. 


GENERAL  PRINCIPLES  OF  SUBSTITUTE  FEEDING  125 

of  such  an  initial  strength  that  when  the  protein  is  sufficiently  reduced 
the  fat  will  still  be  of  a  higher  percentage  than  it;  or  by  replacing  a  cer- 
tain amount  of  the  whole  milk  used  in  the  mixture  by  an  equal  quantity 
of  a  strong  cream  of  known  strength.  The  simple  calculation  necessary 
to  reduce  the  percentage  of  protein,  maintain  that  of  the  fat  and  increase 
that  of  the  sugar,  will  be  more  fully  discussed  in  considering  Home 
Modification.     (See  p.  137.) 

Removal  of  Bacteria.  Sterilizing.  Pasteurizing. — Much  better  than 
the  removing  of  bacteria  is  the  prevention  of  their  entrance.  In  the  best 
milk,  obtained  by  the  method  previously  outlined  (p.  118),  often  no 
treatment  of  any  sort  is  necessary,  the  germs  being  so  few  in  number  that 
the  infant  can  tolerate  them  well.  With  ordinary  milk,  however,  and 
even  with  the  best  milk  in  the  hottest  summer  weather,  some  procedure  is 
needed.  It  must  be  remembered  that  no  degree  of  heat  can  do  more  than 
partially  destroy  the  harmful  toxins  which  may  have  been  formed  already, 
and  which  are  the  cause  of  many  illnesses.  Milk  which  contains  these 
cannot  be  made  fit  to  use. 

Sterilization. — The  term  sterilization  as  commonly  applied  to  milk 
consists  in  the  subjection  of  it  for  a  short  time,  }'4  to  1  hour,  to  a  tempera- 
ture of  212°F.  (100°C.).  This  is  not  strictly  a  sterilization,  since  some 
varieties  of  bacteria  remain,  and  spores  of  others  are  not  destroyed  at  this 
temperature.  The  first  practical  "sterilizer"  for  household  use  in  the 
feeding  of  infants  was  that  devised  by  Soxhlet.^  Since  then  many  have 
been  invented,  that  of  Arnold  being  very  well  known,  all  acting  on  the 
same  principle;  viz.  the  subjecting  of  the  milk  in  closed  bottles  to  the 
action  of  steam,  thus  raising  the  food  to  a  temperature  of  nearly  or  quite 
212°F.  (100°C.).  The  bottles,  previously  boiled,  are  filled  with  as  much 
of  the  milk-mixture  as  is  needed  for  each  feeding;  the  necks  care- 
fully wiped  and  then  stopped  with  sterilized,  non-absorbent  cotton,  and 
the  filled  bottles  stood  in  the  rack  intended  to  hold  them  and  this  then 
placed  in  the  receptacle  and  subjected  to  the  action  of  steam  for  an  hour. 
After  this  the  bottles  should  be  cooled  as  rapidl}^  as  possible,  and  when 
cool  enough  not  to  break  put  upon  ice  and  kept  there. 

The  effect  of  heat  upon  milk  has  already  been  described  (p.  109). 
Sterilizing  at  the  temperature  of  212°r.  (100°C.)  causes  a  certain  degree 
of  decomposition  of  the  sugar;  precipitates  the  lactalbumin;  produces 
some  alteration  of  the  casein,  and  interferes  with  its  coagulation  by 
rennin;  probably  alters  to  some  extent  the  mineral  matter;  destroys  some 
of  the  ferments,  and  decidedly  lessens  the  bactericidal  power,  which  would 
have  tended  to  prevent  the  growth  of  bacteria  for  a  time.  There  is 
reason  to  believe,  also,  that  the  use  of  sterilized  milk  may  sometimes  give 
rise  to  the  development  of  infantile  scurvy.  Yet  in  spite  of  this  list  of 
apparently  important  alterations,  the  danger  from  sterihzation  is  cer- 
tainly over-rated.  There  is  no  positive  proof  that  sterilized  milk  is,  or  is 
not,  less  well  digested  than  is  raw  milk,  in  spite  of  the  large  amount  of 
evidence  offered  upon  each  side  of  the  fiuestion.  It  is  certainly  better  to 
raise  the  milk  to  the  temperature  of  boiling  than  to  employ  it  raw  if  not 
of  the  highest  (|uality. 

Pasteurization. — This  term  had  its  origin  in  the  employment  by 
Pasteur  of  a  temperature  less  than  100°C.  (212°F.)  for  the  preservation 
of  wine.  As  applied  to  infant-feeding  it  consists  in  the  subjection  of  the 
bottles  of  milk-mixture,  prepared  as  for  sterilizing,  to  a  temperature  of 
less  than  boihng;  one  of  from  140  to  165°F.  (60°  to  73.9°C.)  being  ordi- 

'  Miincli.  mcd.  Woch.,   1880,  XXXIII,  27(). 


126 


THE  DISEASES  OF  CHILDREN 


narily  recommended  and  the  heat  maintained  for  from  30  to  60  minutes. 
This  is  sufficient  to  kill  the  pathogenic  bacteria  and  the  larger  number  of 
the  non-pathogenic  organisms.  (See  p.  1 14.)  It  will  not,  however,  destroy 
the  spores  of  the  proteolytic  bacteria.  The  effect  upon  the  chemical 
composition  of  the  milk  is  certainly  less  than  is  the  heating  to  the  boiling 
point,  and  at  140°  or  even  at  150°F.  (60°  to  65.5°C.)  is  practically  absent; 
but  mechanically  a  difference  is  produced,  shown  especially  in  the  im- 
perfect rising  of  the  cream  (p.  109).  Particular  care  must  be  taken  to 
cool  the  milk  rapidly  afterward  and  to  keep  it  cold,  otherwise  the  pro- 
tein is  decomposed  by  the  bacteria  which  may  develop,  and  the  milk, 
although  it  may  not  sour,  is  rendered  especially  dangerous  (Bergey).^ 
Pasteurization  is  a  delicate  process,  since  a  temperature  higher  than  150°F. 
(65.5°C.)  possesses  some  of  the  disadvantages  of  sterilizing,  while  one  lower 
than  140°F.  (60°C.)  does  not  act  sufficiently  upon  the  germs.  To  be 
efficient  it  must  be  done  accurately.  All  such  makeshifts  as  putting  the 
bottles  into  a  dishpan  of  hot  water,  heating  in  a  sterilizer  for  a  certain 
number  of  minutes,  and  the  like,  are  to  be  condemned,  unless  a  careful 
observation  is  made  of  the  actual  degree  of  temperature  attained,  and 

the  duration  of  this.  A  sterilizer  may,  it 
is  true,  be  made  use  of,  taking  care  not  to 
raise  the  temperature  to  that  of  boiling. 
In  this  case,  however,  a  thermometer  must 
be  employed  and  the  temperature  of  the 
water  constantly  watched.  This  is  a 
troublesome  and  time-consuming  method 
and  requires  more  knowledge  than  can  be 
expected  of  an  average  nurse-maid  and  of 
many  mothers.  Various  pasteurizers  have 
been  constructed.  A  very  convenient  and 
accurate  one,  easy  to  use,  has  been  devised 
by  Freeman  (Fig.  21). ^  This  consists  of 
a  metal  pail  with  a  groove  about  its  cir- 
cumference indicating  the  amount  of  water  to  be  put  into  it,  and  a  rack 
to  hold  the  bottles,  each  bottle  fitting  into  its  own  cylindrical  metal 
cup,  which,  when  water  is  poured  around  each  bottle,  prevents  these  from 
cracking  when  exposed  to  the  heat.  In  the  employment  of  the  pasteurizer 
the  pail  is  filled  with  water  up  to  the  grooved  line,  placed  upon  the  stove  or 
other  source  of  heat,  and  the  water  raised  to  the  boiling  point,  replacing 
any  water  which  may  have  boiled  away.  Meanwhile  the  bottles  are  pre- 
pared as  for  sterilization  and  placed  in  the  rack,  and  enough  water  poured 
into  each  cup  to  surround  them.  The  milk  in  the  bottles  should  be  cold, 
and  any  bottles  not  needed  for  food  should  be  ffiled  with  cold  water  and 
put  in  the  rack.  This  is  necessary  to  maintain  the  proper  balance.  The 
pail  is  now  removed  from  the  fire,  set  upon  a  wooden  or  other  non- 
conducting table  out  of  draughts,  the  rack  put  in,  the  lid  put  on,  and  the 
apparatus  allowed  to  stand  for  1  hour.  In  10  minutes  the  temperature 
of  the  milk  has  risen  to  55°C.  (131°F.)  and  in  20  minutes  from  the  begin- 
ning to  shghtly  over  60°C.  (140°F.).  and  this  temperature  is  maintained 
for  the  remaining  40  minutes.  The  lid  is  now  removed  and  cold  water 
from  the  faucet  is  allowed  to  flow  freely  into  the  pail,  overflowing  into 
the  sink.     This  produces  the  rapid  cooling  of  the  bottles  which  is  neces- 

1  Proc.  Path.  Soc.  Phila.,  1905,  102. 

2  Med.  Rec,  1892,  XLIl,  8;  Arch,  of  Ped.,  1896,  595;  Jour.  Amer.  Med.  Assoc, 
1907,  XLIX,  1740. 


Fig.  21. — Freeman  Pasteurizer. 


GENERAL  PRINCIPLES  OF  SUBSTITUTE  FEEDING  127 

sary.  When  sufficiently  cool  they  are  at  once  put  upon  ice  and  kept 
there.  The  Freeman  pasteurizer  has  the  great  recommendation  that  its 
employment  is  perfectly  simple,  and  that  it  requires  no  watching  what- 
ever. Owing  to  the  almost  complete  harmlessness  of  pasteurization,  it 
should  be  employed  with  all  milk  not  produced  under  the  most  careful 
supervision,  and  even  with  this  it  is  advisable  in  hot  weather. 

What  has  been  written  above  applies  entirely  to  home  pasteurization, 
which  is  the  method  always  greatly  to  be  preferred.  In  recent  years 
commercial  pasteurization  has  become  very  extensively  used.  Several 
procedures  have  been  employed.  The  "flash"  method  passes  the  milk 
over  hot  pipes,  heating  it  for  a  few  seconds  to  the  temperature  of  about 
170°F.  (76.7°C.).  It  is  entirely  untrustworthy.  The  "holding"  method 
maintains  the  milk  at  140  to  155°F.  (60°  to  68.3°C.)  for  20  minutes  or 
longer.  This  method  is  satisfactory  if  properly  done;  but  in  its  commer- 
cial application  it  easily  fails  of  attaining  the  desired  temperature.  As 
shown  by  Schorer  and  Rosenau,^  the  safest  commercial  method  is  to 
pasteurize  in  sealed  bottles,  but  at  least  30  minutes  should  be  allowed  to 
raise  the  milk  to  145°F.  (62.8°C.),  and  this  temperature  maintained  for 
30  minutes  more.  Certainly  any  pasteurizing  done  commercially  with- 
out strict  supervision  is  liable  to  be  dangerous.  The  dealer  is  tempted  to 
employ  the  cheapest  method  which  will  retard  the  growth  of  the  lactic- 
acid-producing  organisms  and  prevent  souring;  while  for  the  physician 
souring  is  the  least  of  the  evils  which  maj^  occur,  and  may  be  a  valuable 
index  that  the  milk  is  not  fit  for  use.  The  proteolytic  germs  are  far  more 
dangerous  to  the  infant.  Further,  the  purchasing  of  pasteurized  milk  by 
the  mother,  independently  of  medical  advice,  gives  her  a  false  sense  of 
security  and  engenders  lack  of  sufficient  care  of  the  milk  after  it  has  been 
delivered.  As  a  matter  of  fact,  all  pasteurized  milk  requires  the  same 
care  in  keeping  it  cold  that  applies  to  the  handling  of  raw  milk.  Per- 
haps the  greatest  disadvantage  of  commercially  pasteurized  milk  deliv- 
ered in  the  bottle  as  whole  milk,  is  the  unsatisfactory  manner,  already 
referred  to,  in  which  the  cream  rises.  This  makes  the  employment  of 
either  top  milk  or  skimmed  milk  subject  to  great  uncertainty.  The  fat 
in  the  former  is  less  than  it  should  be,  and  that  in  the  latter  often  so 
great  that  in  cases  of  disturbed  digestion  a  sufficiently  low  fat-percentage 
cannot  be  obtained. 

The  Action  of  the  Different  Food=elements.— Although  a  cow's 
milk-mixture  which  contains  percentages  similar  to  those  of  human  milk, 
and  which  possesses  the  requisite  nuniber  of  calories,  theoretically  should 
agree  with  and  properly  nourish  the  human  infant,  yet,  as  already  pointed 
out  (p.  120)  the  insurmountable  differences  between  the  two  varieties  of 
milk  make  this  not  at  all  the  necessary  result.  As  a  matter  of  fact, 
many  variations  from  the  standard  are  often  required.  It  is  imj)ortant 
to  understand  the  action  of  the  different  milk-elements  in  health  and  in 
the  production  of  symptoms  of  indigestion,  and  with  this  knowledge,  to 
change  one  or  another  until  the  suitable  food  is  obtained.  This  action 
has  already  been  studied  to  some  extent  in  discussing  the  absorption  and 
metabolism  of  breast-milk  (pp.  48  and  52),  and  the  action  of  the  differ- 
ent elements  of  breast-milk  (p.  99).  It  is  rare,  in  my  experience,  that 
a  healthy  infant  cannot  be  fed  with  reasonable  success  upon  cow's  milk, 
if  it  has  been  properly  started.  The  problem  arises  in  the  case  of  those 
who  have  already  been  improperly  fed.  Occasionally,  it  is  true,  an 
idiosyncrasy  to  cow's  milk  is  encountered,  and  such  infants  cannot  take  it 
1  Journ.  Med.  Research,  1912,  XXVI,  127;  Amer.  Jour.  Dis.  Child.,  1912,  III,  22G. 


128  THE  DISEASES  OF  CHILDREN 

at  all.  This  condition  is  generallj^  an  acquired  one,  dependent  probably 
upon  an  anaphylaxis  to  cow's  milk-protein  developed  through  faulty 
efforts  to  feed  this  during  a  period  of  indigestion  in  very  early  infancy. 
The  action  of  the  ferments  may  be  ignored  in  this  connection,  as  we  know 
comparatively  little  of  the  actual  part  played  by  them  in  the  diet.  The 
mutual  influence  which  the  different  elements  of  the  food  exert  upon 
each  other  is,  however,  a  matter  of  importance  and  is  receiving  increasing 
attention. 

Fat. — The  fat  of  the  milk-mixture  is  the  element  most  easily  causing 
digestive  and  nutritional  disturbances,  and  many  infants  show  a  great  and 
persistent  intolerance  for  it.  While  in  theory  4  per  cent,  should  be  well- 
borne,  this  being  the  amount  existing  in  human  milk,  it  is  usually  neces- 
sary, in  my  experience,  to  use  decidedly  less  than  this  in  making  a  milk- 
mixture,  owing  to  the  excess  of  volatile  fatty  acids  present  in  cow's  milk. 
This  is  particularly  the  case  in  very  young  healthy  infants,  and  in  others 
older  whose  digestion  has  been  impaired  by  illness.  For  all  such  an 
initial  percentage  of  0.5  or  1.0  per  cent,  is  to  be  selected,  and  the  increase 
above  this  made  very  carefully.  Even  with  those  who  have  shown  a 
power  to  digest  cow's  milk-fat,  3  per  cent,  or  at  most  3.5  per  cent,  is 
generally  as  high  as  it  is  safe  to  go.  This  is  especially  true  in  home- 
mocUfications  if  portions  of  top-milk  and  bottom-milk  have  been  com- 
bined, since  in  the  latter  there  is  a  certain  amount  of  fat  present  which 
increases  the  percentage  shghtly  above  that  indicated  by  the  calculation. 
Fat  is  indeed  the  commonest  cause  of  frequent  sour  vomiting  with  the 
rancid  odor  of  butyric  acid,  although  an  excess  of  sugar  may  likewise 
produce  sour,  watery  regurgitation.  So,  also,  if  the  fat  is  in  too  large 
an  amount  it  combines  with  the  heavier  alkahes,  as  calcium  and  magne- 
sium, and  produces  soap-stools;  or,  uniting  with  potassium  or  sodium 
causes  diarrhea  with  white,  soft  curds.  The  increase  of  the  carboy 
hydrates  will  sometimes  cause  the  fat  to  be  absorbed.  Where  there  is 
an  unusual  intolerance  for  the  fat  of  cow's  milk,  this  element  must  be 
withdrawn,  or  reduced  in  amount.  For  this  purpose  butter-milk  (p.  147) 
is  suitable.  Efforts  have  been  made  to  use  other  lands  of  fat,  especially 
ohve  oil  (Ladd).'  It  is  necessary,  however,  to  have  this  made  into  an 
extremely  fine  emulsion  by  a  special  process.  Even  lard  and  cocoanut  oil 
have  been  tried  (Gerstenberger,  et  ai.)."^ 

A  very  common  practice  with  many  physicians  is  the  giving  of  a  food- 
mixture  rich  in  cream  for  the  sake  of  overcoming  constipation.  This  is  a 
dangerous  procedure  in  infants  in  the  1st  year;  and  there  are  better  ways. 
On  the  other  hand,  it  is  to  be  remembered  that  fat  produces  more  than 
twice  as  many  calories  as  do  the  other  milk-elements,  and  that  without 
a  sufficient  amount  of  it  the  quantity  of  food  necessary  to  supply  these 
may  be  unduly  great.  Infants  who  are  not  able  to  take  a  normal  amount 
of  fat  are  liable  to  be  insufficiently  nourished. 

Carbohydrate. — The  sugar  of  the  milk  is  generally  digested  well. 
It  is  seldom  necessary  to  begin  with  less  than  5  per  cent.,  and  under 
ordinary  circumstances  it  is  not  required  to  increase  beyond  6  or  7  per 
cent.  Much  discussion  has  arisen  as  to  the  variety  of  sugar  which  should 
be  employed.  Usually  it  would  seem  best  to  select  lactose  for  this  pur- 
pose. This  is  the  natural  sugar  of  the  food,  and  by  its  slower  absorption 
tends  to  remain  longer  in  the  intestine,  favoring  the  growth  of  the  normal 
intestinal  flora.     It  also  undergoes  butyric  acid  fermentation  less  readily 

1  Transac.  Amer.  Pcd.  Hoc,  1915,  XXVII,  117. 

2  Transac.  Amer.  Fed.  Soc,  1915,  XXVII,  94. 


GENERAL  PRINCIPLES  OF  SUBSTITUTE  FEEDING  129 

than  does  maltose,  and  is  better  tolerated  than  is  this  or  cane-sugar 
when  there  is  disordered  gastric  digestion  with  vomiting.  On  the  other 
hand,  under  the  influence  of  abnormal  bacterial  growth,  lactose  may  be- 
come more  harmful  than  other  sugars.  Where  a  rapid  absorption  and 
increase  of  weight  is  desired,  saccharose  and,  especially,  dextrin-maltose 
preparations  are  to  be  preferred.  They  are  serviceable  in  this  way  when 
on  account  of  difficulty  in  the  digestion  of  fat  it  is  necessary  to  supply  the 
requisite  calories  by  giving  a  high  carbohydrate  diet. 

The  carbohydrate  in  the  food  tends  to  favor  the  digestion  of  the  pro- 
tein, and  when  administered  in  high  percentage  will  often  change  com- 
pletely the  character  of  stools  showing  protein  indigestion.  It  often 
favors,  too,  the  absorption  of  the  fat ;  perhaps  by  increasing  the  acidity  of 
the  intestinal  tract  and  thus  preventing  the  union  of  the  fatty  acids  with 
the  alkahes  to  form  soap-stools.  If,  however,  given  in  excess,  any  form  of 
sugar  may  cause  diarrhea,  and  a  consequent  diminished  absorption  of  the 
food-elements.  Not  more  than  7  per  cent,  of  lactose  should  be  adminis- 
tered (Morse  and  Talbot), ^  and  when  larger  percentages  of  carbohydrate 
are  required,  a  dextrin-maltose  preparation  or  starch  is  better. 

The  term  "maltose"  as  used  in  the  feeding  of  infants  is  generally 
employed  to  designate  one  of  the  combinations  of  dextrin  and  maltose 
on  the  market.  There  are  a  number  well  known,  such  as  Soxhlet's 
Nahrzucker,  the  malt-soup  extracts,  neutral  maltose,  and  others  and  all 
may  be  denominated  here  "dextrin-maltose  preparations."  They  consist 
of  combinations  of  maltose  and  of  dextrin,  produced  in  the  dextrinizing 
of  starch.  (See  p.  155.)  Similar  preparations  rnay  be  made  at  home. 
The  percentage  of  maltose  ranges  roughly  from  40  to  60  per  cent,  and  of 
the  dextrin  from  10  to  60  per  cent.  The  preparations  containing  the 
more  maltose  are  more  rapidly  absorbed,  but  on  the  other  hand  are  more 
liable  to  produce  diarrhea,  and  those  with  considerable  dextrin  are  to  be 
preferred.  The  following  table  of  analyses  is  in  part  that  given  by 
Southworth,-  with  the  addition  of  figures  for  the  Maltine  Company's,^ 
Borcherdt's*  and  the  Freihofer  Company's^  products.     Some  of  these 

Table  43. — Maltose  and  Dextrin  op  Malt-extracts 

Maltose,  per  cent.  Dextrin,  per  cent. 


Soxhlet's  Nahrzucker 

Loeflund's  Nahrmaltose 

Dextri-maltose  (Mead-Johnson) . . 
Neutral  Maltose  (Maltzyme  Co.) 
Loeflund's  Malt-soup  Extract... 
Borcherdt's  Malt-soup  Extract. . . 
Maltine  Co.  Malt-soup  Extract .  . 
Freihofer  Co.  Malt  Extract 


52.44 

41.21 

40.00 

60.00 

51.00                   f 

47.00 

63.00-6G.00       ' 

8.0-9 

58.91 

15.42 

57.57 

11.70 

62.3 

3.003 

Gl.O 

0.0 

preparations  are  distinctly  acid,  and  the  addition  of  from  5  to  10  grains 
(0.32  to  0.65)  of  potassium  carbonate  to  the  ounce  is  advisable.  (See 
also  p.  156.) 

Many  disordered  conditions  of  the  digestion  have  been  attributed  to 
the  influence  of  the  sugar  of  the  food,  and  without  question  with  more  or 

1  Diseases  of  Nutrition"  and  Infant  Feeding,  1915,  264. 

2  Arch,  of  Fed.,  1912,  XXIX,  652. 
'Advertisement. 

*  Adverti.soinont. 

^  Information  roceivcMl  from  luanufacturcr. 


130  THE  DISEASES  OF  CHILDREN 

less  reason.  Yet  a  careful  review  of  the  subject  by  Porter  and  Dunn,^ 
combined  with  their  own  experiments,  led  to  the  conclusion  that  the 
danger  of  severe  symptoms  from  the  giving  of  the  sugars  in  considerable 
amount  has  been  greatly  exaggerated. 

Starch. — It  very  frequently  is  of  great  advantage  to  employ  the 
addition  of  starch  in  the  food-mixture.  Its  caloric  value  is  practically 
the  same  as  that  of  sugar.  Although  the  pancreatic  secretion  possesses 
amylolytic  power  even  at  birth,  this  is  only  slight  before  the  age  of  2 
or  3  months,  and  when  starch  is  given  before  this  age  it  is  for  purposes 
other  than  absorption,  such,  for  instance,  as  the  prevention  of  the  forma- 
tion of  curds.  In  the  form  of  barley-water  or  other  amylaceous  decoctions 
it  is  often  of  great  service.  There  is  no  reason,  however,  to  give  starch 
to  every  infant  as  a  routine  measure.  In  fact  it  should  be  used  only  for  a 
definite  purpose  and  in  definite  percentage-strength.  Generally  1  per 
cent,  at  most  is  sufficient  for  simple  dilutions.  A  table  of  the  strength  of 
various  cereal  decoctions  will  be  given  later  (p.  154). 

Starch  is  an  extremely  useful  carbohydrate  in  those  cases  where  a 
high  percentage  of  this  latter  is  required,  being  often  better  tolerated  when 
combined  with  a  dextrin-maltose  preparation  than  is  the  latter  when  given 
alone.  It  is  the  existence  of  this  combination  which  makes  the  malt- 
soup  preparations  so  serviceable  in  many  instances  (p.  156).  This  is 
probably  in  part  due  to  the  mechanical  colloidal  action  of  the  starch 
upon  the  protein,  and  in  part  dependent  upon  the  slower  breaking  up  of 
the  starch-molecule  as  compared  with  sugar  and  dextrin.  If,  however, 
starch  is  given  continuously  in  excessive  amounts,  and  especially  if 
without  the  addition  of  milk,  or  with  only  small  amounts  of  it,  severe 
symptoms  may  arise.  The  infant  becomes  pale,  flabby  and  perhaps  too 
plump;  indigestion  with  diarrhea  develops;  there  is  undue  fermentation 
in  the  alimentary  tract,  with  loss  of  power  of  digestion  and  the  de- 
velopment of  a  wasted  condition,  or  sometimes  of  increase  of  weight 
dependent  in  part  upon  an  extensive  edema.  (See  Injury  from  Starch, 
p.  616.) 

Protein. — Other  things  being  equal,  the  protein  of  milk,  and  especially 
the  casein,  is  tolerated  in  relatively  liigh  amount,  and  seldom  produces 
disturbances  of  digestion.  Yet  it  is  better  to  begin  with  not  over  1  per 
cent,  in  the  mixture,  and  then  gradually  increase  this  as  the  needs  demand. 
The  quantity  required  by  the  infant  is  not  very  large,  although  greater 
relatively  than  in  the  adult.  The  average  minimum  amount  is  1.5  grams 
per  kilogram  of  body-weight  (10.5  grains  per  pound),  and  many  infants 
need  slightly  more  than  this  (p.  50).  The  great  difference  between  the 
protein  and  the  other  elements  is  that  whereas  these  may  replace  each 
other  to  some  extent  this  amount  of  protein  is  absolutely  required,  and 
can  be  substituted  by  nothing  else.  Infants  fed  upon  a  diet  insufficient 
in  protein  cannot  really  thrive.  Although  they  may  often  be  quite  fat,  per- 
haps from  the  large  amount  of  carbohydrate  which  has  been  administered, 
they  are  anemic,  flabby  and  possess  little  actual  strength  or  muscular 
development.  As  regards  the  different  proteins  of  the  milk,  it  has  been 
claimed  in  many  quarters  that  the  casein  is  always  tolerated  in  high  per- 
centage provided  that  of  the  whey  is  reduced;  the  benefit  from  the  reduc- 
tion depending  probably  upon  the  diminution  in  the  amounts  of  sugar 
and  of  salts  rather  than  of  the  lactalbumin.  This  requires  further  con- 
firmation, and  there  is  decided  evidence  opposed  to  it.  It  would  seem 
probable,  for  instance,  that  the  improvement  in  symptoms  undoubtedly 

1  Amer.  Jour.  Dis.  Child.,  1915,  X,  77. 


GENERAL  PRINCIPLES  OF  SUBSTITUTE  FEEDING  131 

sometimes  seen  after  the  employment  of  peptonizing,  once  so  much  in 
vogue,  would  indicate  that  the  percentage  of  casein  was  not  the  matter 
of  indifference  which  has  been  maintained.  There  is  further  no  question 
from  the  experience  of  many  physicians  that  many  ill  infants  will  thrive 
on  whey-mixtures  who  have  done  badly  upon  food  containing  considerable 
casein.  This  would  seem  reasonably  to  be  expected  when  one  considers 
the  comparatively  large  amount  of  whey-protein  in  human  milk  as  com- 
pared mth  the  casein.  (See  table  42,  p.  119.)  For  many  years  whey- 
cream  mixtures  were  popular  with  physicians,  and  deservedly  so  in  selected 
cases.  In  fact,  it  has  been  pointed  out  (Holt)i  that  sometimes  the  feeding 
with  high  casein-percentages  may  not  be  tolerated  unless  whey,  with  its 
comparatively  high  carbohydrate  content  is  present  also;  and  that,  further, 
the  whey  is  needed  on  account  of  the  large  percentage  of  certain  amino- 
acids  present  in  it.  Sometimes  the  whey  in  the  mixture  is  well  borne  if 
the  fat-percentage  is  low,  as  is  the  case  when  buttermilk  is  employed. 

Sometimes  the  proteid-matter  of  milk  is  found  in  the  stools  as  hard, 
yellowish-white  curds  (see  p.  50),  but  this  appears  to  be  of  httle  moment 
unless  the  curds  are  very  numerous,  and  seems  to  be  prevented  if  the 
milk  has  been  heated  to  a  high  temperature,  or  by  other  measures  already 
discussed  (p.  124).  Failure  to  digest  protein  also  often  results  in  the 
development  of  offensive,  green,  diarrheal  stools,  or  of  soap-stools  with 
an  offensive  odor. 

Much  has  been  written  concerning  the  digestibihty  and  absorption 
of  foreign  proteins  and  the  deleterious  effects  which  may  or  may  not  occur. 
The  subject  has  already  been  alluded  to.  (See  p.  50.)  There  seems  to  be 
no  question  that  such  results  can  follow.  In  the  cases  described  by 
Benjamin-  there  was  pallor,  great  atony,  free  perspiration  and  sometimes 
eczema.  In  an  instance  reported  by  Hoobler^  a  decidedly  stuporous 
condition  developed,  whereas  in  cases  reported  by  Holt  and  Levene* 
there  was  continued  fever.  The  influence  of  foreign  proteins  in  the  food 
even  when  in  small  amount  may  sometimes  show  itself  in  other  ways. 
Thus,  for  instance,  in  the  early  weeks  of  Kfe,  and  especially  in  infants 
suffering  from  any  gastro-intestinal  or  nutritional  disorder,  it  is  possible  for 
the  foreign  protein  to  pass  unaltered  or  partly  digested  through  the  intesti- 
nal wall  and  to  produce  modified  evidences  of  anaphylaxis.  In  some  in- 
stances this  amounts  to  an  actual  idiosyncrasy,  and  certain  foreign  pro- 
teins, even  in  very  small  quantity,  cause  decided  and  at  times  alarming 
symptoms,  even  in  apparently  healthy  infants  and  in  older  children.  Tliis 
may  occur  with  the  casein  of  cow's  milk,  but  an  actual  anaphylactic  condi- 
tion of  this  nature  produced  by  it  is  certainly  uncommon.  Oftener  it  is 
seen  in  older  children,  and  is  especially  noticed  with  the  protein  of  egg  or 
of  certain  of  the  cereals,  varying  with  the  case.  Very  similar  symptoms 
can  sometimes  be  occasioned  by  other  food-stuffs,  such  as  certain  fruits. 
The  symptoms  consist  not  only  in  severe  gastro-intestinal  manifestations, 
but  in  nervous  disturbances  including  prostration,  cutaneous  eruj)tions, 
dyspnea,  sneezing,  wheezing  respiration,  and  other  symptoms  suggestive 
of  an  asthmatic  attack.  Cutaneous  tests  upon  children  have  been  made 
with  the  various  proteins  by  Schloss,*  Talbot,"  and  others,  which  confirm 
the  cHnical  experience  that  it  is  the  protein  which  is  the  active  cause  of 

'  Arch,  of  Ped.,  1916,  XXXIII,  13. 

2Zeitschr.  f.  Kindorh.,  OriR.,  1914,  X,  183. 

3  Amer.  .Jour.  I)i.s.  Cliild.,  191.''),  X,  153. 

*  Amer.  .lovir.  Dis.  Child.,  1912,  IV,  206. 

^Amcr.  Jour.  Dis.  Ciiild.,  1912,  III,  341. 

6Bost.  Med.  and  Surg.  Journ.,  1918,  CLIXXIX,  285. 


132  THE  DISEASES  OF  CHILDREN 

the  disturbance.  Various  protein-preparations  to  be  used  for  cutaneous 
testing  are  now  on  the  market  commercially. 

Mineral-matter. — The  salts  are  certainly  necessary  for  the  life  of  the 
infant,  and  are  absorbed  and  retained  in  proportion  to  the  retention  of 
nitrogen.  With  the  exception  of  iron  they  are  present  in  cow's  milk 
to  an  excess  which  renders  them  sufficient  for  the  infant  given  any 
ordinary  dilution.  It  has  been  claimed  that  they  are  not  always  well 
tolerated,  and  that  the  reduction  of  the  salts  and  of  the  sugar,  as  results 
from  the  removal  or  reduction  of  the  whey,  is  of  service  in  some  cases 
of  difficult  digestion.  The  whole  question  of  the  part  played  by  the 
salts  in  digestion  is,  however,  far  from  being  understood.     (See  also  p.  51.) 

The  Selection  of  Percentages.^ — -What  follows  may  be  regarded  in 
the  fight  of  a  summary  of  the  substance  of  the  preceding  sections.  At 
the  outset  it  must  be  clearly  stated  that  it  is  impossible  to  formulate  any 
fixed  rules  for  the  percentage-strength  of  the  milk-ingredients  which  even 
the  normal  child  will  require.  The  tables  often  pubfished  showing  the 
strengths  to  be  used  at  different  ages  are  liable  to  be  misleading  and 
harmful,  in  that  they  tend  to  make  the  inexperienced  practitioner  attempt 
to  fit  the  baby  to  the  table,  rather  than  the  food  to  the  baby.  The  fact 
has  already  been  pointed  out  that  after  the  early  weeks  the  proportions 
of  the  ingredients  of  human  milk  do  not  alter  materially.  The  infant 
simply  takes  a  larger  quantity  as  it  grows  older.  In  artificial  feeding,  on 
the  other  hand,  owing  to  the  difficulty  in  the  digestion  of  the  fat  and 
the  differences  in  composition  between  the  proteins  of  cow's  milk  and 
of  human  milk,  the  percentage  of  these  latter  in  the  mixture  usually 
must  be  raised,  as  otherwise  the  bulk  of  the  food  required  to  supply  the 
protein  needed  might  be  far  too  great  if  properly  diluted.  The  only 
dependable  guide  is  the  state  of  the  general  health  of  the  infant,  the 
condition  of  its  digestion,  and  the  rate  of  growth  in  weight.  To  make* 
the  age  by  months  the  guide  is,  I  believe,  a  serious  error.  Should  the 
health  and  weight  be  all  that  can  be  desired,  increase  in  the  strength  of 
the  food  in  any  respect  is  to  be  made  cautiously  if  at  all.  If  the  condition 
indicates  an  insufficient  food-supply,  the  quantity  is  to  be  increased  or 
the  percentages  raised.  If  digestive  disturbances  arise,  the  food  must 
be  further  modified.  There  are  naturally  certain  percentages  wliich 
experience  has  taught  that  the  average  child  can  be  expected  to  take  at 
certain  ages;  but  the  feeding  of  each  individual  infant  is  a  matter  of 
trial,  since  no  one  can  know  in  advance  what  the  tolerance  for  cow's 
milk  will  prove  to  be. 

With  these  fimitations  the  following  directions  may  be  given  as  a 
general  guide:  The  healthy  infant  in  the  first  few  weeks  of  life  may  be 
started  with  such  a  formula  as  fat  1  per  cent.,  milk-sugar  5  per  cent., 
and  protein  1  per  cent.  Very  probably  there  will  be  no  gain  in  weight, 
or  even  a  slight  loss  with  this  weak  mixture,  and  it  is  likely  that  a  stronger 
initial  one  could  have  been  used.  It  is  safer,  however,  to  begin  with  the 
low  formula  in  order  to  test  the  effects  upon  digestion.  There  is  no 
hurry  about  the  gain  in  weight.  To  accustom  the  infant  to  its  new  food 
and  not  to  disturb  the  digestion  are  the  important  matters.  If  the  food 
agrees  well  it  may  be  changed  in  a  few  days  to  fat  1.5  per  cent.,  and 
then  again  to  fat  2  per  cent.,  sugar  6  per  cent.,  and  protein  1.5  per  cent. 
These  changes,  of  course,  go  hand  in  hand  with  an  increase  in  the  quan- 
tity, which  will  be  considered  in  the  next  section.  With  such  a  formula 
as  the  last  given  the  infant  may  be  quite  contented  and  thrive  well  for 
a    considerable    time.     Should,    however,    the   digestion    be   in   perfect 


GEXERAL  PRINCIPLES  OF  SUBSTITUTE  FEEDING  133 

order  but  the  infant  hungry  and  the  weight  at  a  stand.still,  the  strength 
must  be  increased  to  fat  2.5  or  3  per  cent.,  sugar  6  or  7  per  cent.,  and 
protein  1.5  or  2  per  cent.  It  is  manifest  that  hunger  may  be  satisfied 
and  gain  in  weight  accomplished  by  giving  an  unduly  large  quantity  of  a 
weak  formula,  but  the  poUcy  is  not  a  good  one.  After  the  age  of  6 
months  it  is  generally  necessary  to  make  a  further  increase  in  the  strength 
of  the  food,  giving  perhaps  fat  3  or  3.5  per  cent.,  sugar  5  or  6  per  cent., 
and  protein  2  or  3  per  cent.  The  frequent  diflBculty  in  digesting  fat 
should  still  be  borne  in  mind,  and  in  most  cases  an  amount  over  3  per 
cent,  should  be  tried  with  great  caution.  Many  infants  even  at  a  year 
of  age  cannot  take  entirely  undiluted  cow's  milk.  What  changes  shall 
be  made  in  the  food,  what  elements  increased  or  decreased  in  amount, 
is  to  be  determined  by  a  study  of  the  effects,  as  outHned  in  the  preceding 
section  (p.  127j.  The  method  of  preparing  the  food-mixture  containing 
the  percentages  de.sired  ^ill  be  considered  in  the  sections  upon  Labo- 
ratory-modification (p.  134)  and  Home-modification  (p.  134)  of  the 
milk. 

The  Quantity  of  Food  and  the  Frequency  of  Feeding. — The 
quantity  of  the  milk-mixture  to  be  given  varies,  of  course,  with  the  age, 
and  approximates  the  table  for  the  amount  of  breast-milk  as  given  on 
p.  92.  The  frequency  of  feeding,  too;  the  hours  for  this;  and  the  relation 
of  feeding  to  sleep,  are  governed  by  the  principles  wliich  control  breast- 
feeding (p.  84),  and  the  following  table,  an  elaborated  form  of  that 
upon  p.  85,  gives  an  approximation  of  the  frequency  and  the  amounts 
for  each  feeding  at  different  ages,  the  quantity  Vjeing  gradually  increased 
as  the  age  advances: 

T.\BLE  44. — Interv.^ls  .\nd  A.MOUNT.S  FOR  Artifici.al  P'eedi.vg 


Age 

Intervals  of 
feeding,  hours 

Xumber  of 

feedings  in  24 

hours 

Number  of 
feedings  at 
night  after 
10  P.M.  and 
before  6  a.m. 

Amount  at 

each  feeding, 

ounces 

1 

Total  amount 

in  24  hours, 

ounces 

1 

1  to  4  weeks 

4  week.s  to  3  months 

3  to  4  or  5  months. . 

4  or  5  months  to  1 
vfar. 

2-2M 
2K-3 

3-3M 
3-4 

8-10 

7-8 
6-7 
5-6 

2 

1 

K?) 

0 

1 

1-2 
2H-5 
4-6 
6-10 

'       10-20 
20-21 
28-36 
30-50 

The  length  of  the  intervals  and  the  number  of  feedings  are  much  the 
same  as  for  breast-feeding,  and  the  divergence  of  opinions  regarding  the 
matter  has  been  referred  to  in  that  section.  There  is,  of  course,  much 
latitude  to  be  allowed  in  using  the  table,  dependent  upon  the  digestion 
and  the  demands  of  the  child.  Regularity  is  important,  but  the  amount 
taken  at  a  feeding  and  the  number  of  feedings  in  the  twenty-four  hours 
vary  greatly  with  the  case.  An  infant  always  hungry  may  need  to 
exceed  the  amount  for  its  age  or  to  be  fed  at  shorter  intervals;  another 
with  large  appetite  may  need  longer  intervals.  It  is  important,  too,  to 
be  guided  considerably  by  the  weight.  An  unusually  large  child  may 
require  more,  while  a  small  marantic  infant  may  be  able  to  take  only 
much  less  than  the  age  calls  for.  There  can  V)e  no  fixed  rule.  In  general, 
a  healthy  infant  may  have  all  Ihe  food  it  will  take  at  the  feeding-time, 
provided  it  can  retain  and  digest  it;  but  care  should  be  observed  that  an 
unusually  large  appetite  is  not  dependent  upon  the  giving  of  too  weak 
a  formula. 


134  THE  DISEASES  OF  CHILDREN 

Laboratory=modification  of  Milk. — Through  the  efforts  of  "Dr. 
Rotch/ably  seconded  by  Mr.  G.  E.  Gordon  the  principle  of  the  "Milk 
Laboratory"  was  evolved,  and  one  such  established  in  Boston  in  189] 
by  the  Walker-Gordon  Laboratory  Company.  Similar  laboratories 
have  since  been  organized  in  many  of  the  larger  cities  of  the  United 
States  and  in  London.  These  institutions  have  been  of  the  greatest 
benefit  in  giving  an  impetus  to  the  scientific  feeding  of  infants.  Their 
object  is  to  prepare  and  furnish  any  percentage  food-combination 
ordered  by  the  physician,  including  those  in  which  "differential  protein" 
feeding  is  employed;  i.e.  in  which  the  lactalbumin  and  casein  are  pre- 
scribed separately;  and  those  in  which  cereal  decoctions  of  known  strength, 
buttermilk,  and  the  Hke  take  a  part.  The  physician  merely  writes  a 
prescription  calling  for  the  various  percentages  he  needs,  the  total  number 
of  bottles,  the  amount  of  food  for  each,  the  nature  of  the  diluent,  the 
alkahnity,  and  any  other  requirement  desired.  If  the  food  is  to  be 
pasteurized  or  sterilized,  a  starchy  addition  to  be  dextrinized,  acidula- 
tion  by  lactic  acid  bacilli  to  take  place,  or  any  other  change  made,  this 
is  specified  in  the  prescription.  It  is  manifest  that  a  milk-laboratory 
is  not  only  a  great  convenience  to  the  physician  to  whom  it  is  accessible, 
but  that  the  resulting  mixtures  will  be  more  accurately  compounded 
than  when  made  at  home;  since  the  employees  are  certainly  better 
trained  than  is  the  mother  or  the  nurse,  and  a  careful  control  can  be 
kept  over  the  percentage-strength  of  the  milk  and  cream  used.  Unfor- 
tunately the  price  of  laboratory  modified  milk  is  necessarily  considerably 
higher  than  persons  of  restricted  means  can  afford,  and  for  this  reason, 
as  well  as  on  account  of  the  usual  inaccessibility  of  a  laboratory  for  the 
majority  of  infants,  home-modification  is  that  which  must  be  oftenest 
adopted. 

The  Home=modification  of  Milk. — The  calculation  by  the  phy- 
sician of  the  desired  formulae  is  in  reahty  a  very  simple  process.  The 
preparation  of  the  food  can  be  carried  out  by  any  ordinarily  intelligent 
and  properly  directed  mother  or  nurse.  The  chief  advantage  of  home- 
modification  consists  in  its  economy  as  compared  with  laboratory  feeding. 
Although  less  accurate  than  this  latter,  it  approaches  it  closely  if  a 
cream  of  definite  known  strength  can  be  procured;  and  even  for  home- 
prepared  whole-milk  or  top-milk  mixtures  it  is  quite  sufficiently  accurate 
for  ordinary  purposes.  This  is  especially  true  since  the  possibiHty  has 
extended  so  widely  of  procuring  milk  certified  by  a  recognized  Milk 
Commission.  Milk  of  this  sort  should  be  obtained  whenever  feasible; 
and,  when  not,  the  requirements  described  (p.  117)  should  be  fulfilled 
as  far  as  possible.  It  is  particularly  important  that  it  be  of  a  fairly 
uniform  strength  in  fat,  and  not  over  4  per  cent.  When  it  is  necessary 
to  employ  the  richer  milk,  a  slight  change  in  the  procedure  is  required. 
(See  pp.  117  and  139.) 

Many  unwarranted  statements  have  been  made  and  published  re- 
garding the  difficulty  supposed  to  attend  the  preparation  of  milk-mix- 
tures in  the  home,  and  the  complications  involved  in  the  prescribing 
of  these  by  physicians.  Percentage-feeding  and  home-modification 
may  be  made  unnecessarily  difficult,  it  is  true,  but  do  not  in  any  way 
need  to  be  so.  The  calculation  of  the  desired  percentages  (p.  137)  may, 
as  already  indicated,  be  made  by  any  physician  with  the  simplest  school- 
boy knowledge  of  arithmetic.  It  is  not  so  much  lack  of  knowledge  as 
unwilHngness  to  take  trouble  which  interferes  on  the  part  of  the  physician; 
1  Arch,  of  Ped.,  1893,  X,  97. 


ARTICLES  REQUIRED  IN  PREPARING  THE  FOOD  135 

but  to  prescribe  the  best  obtainable  food  for  the  baby  is  so  important 
that  there  can  be  no  possible  excuse  for  any  physician  who  will  not  under- 
take to  do  this  in  the  best  way.  The  objection  that  home-modification 
of  milk  is  too  complicated  for  the  mother  is  so  futile  that  it  hardly  merits 
consideration.  The  mother  is  obUged  to  modify  the  milk  in  some  way, 
and  it  can  certainly  cause  no  more  trouble  to  dilute,  say,  the  upper  half  of 
a  quart  of  milk  with  water,  than  to  dilute  the  whole  quart;  nor  is  the 
addition  of  skimmed  milk  and  water,  or  top-milk  and  water,  to  the  mix- 
ture any  more  comphcated  than  the  adding  of  water  alone.  The  sim- 
plest way  is  the  best  way;  and  if  the  desired  results  can  be  obtained  by 
the  dilution  of  whole  milk  with  water,  this  may  well  be  done.  But  in 
the  very  numerous  instances  where  a  mixture  is  required  in  which  the 
percentage  of  the  fat  is  greater  than  that  of  the  protein,  it  is  only  by  the 
employing  of  a  top-milk  that  the  results  can  be  obtained.  With  the  aid 
of  clear,  concise,  written  directions  there  is  little  chance  of  error;  and 
mothers  to  whom  the  first  preparation  of  any  milk-mixture  seems  difficult 
rapidly  find  the  processes  becoming  easy.  But  if  the  physician  is 
hazy  in  his  own  mind  regarding  the  matter,  or  neglects  to  give  explicit 
instructions,  the  mother  naturally  grows  confused  and  discouraged,  what- 
ever sort  of  food  is  ordered  and  whatever  method  employed. 

Articles  Required  in  Preparing  the  Food.— Bottles. — These  should  be  of 
well  annealed  glass  to  prevent  breaking  when  exposed  to  heat.  They 
may  be  of  any  shape  desired,  but  are  best  narrow  and  cylindrical,  since 
they  occupy  less  space  when  of  this  form,  and  fit  better  in  the  pasteur- 
izer. The  mouths  of  the  bottles  should  be  rather  wide,  rendering  cleans- 
ing easier.  The  bottles  must  be  perfectly  smooth  within,  without  angles 
or  depressions  which  can  collect  milk.  A  series  of  markings  pressed  into 
the  glass  indicate  the  number  of  ounces  of  contained  fluid.  There  should 
be  enough  bottles  provided  to  permit  of  all  the  food  for  twenty-four  hours 
being  prepared  at  one  time. 

Nipples. — These  are  preferably  of  black  rubber  and  of  conical  or 
slightly  bulbous  shape.  The  openings  should  be  only  large  enough  to 
allow  the  milk  to  drop  easily  when  the  filled  bottle  is  inverted,  but  not  to 
run  from  it  in  a  stream.  If  the  holes  are  not  of  sufficient  size  they  may 
be  enlarged  with  a  red-hot  needle.  As  the  nipple  gets  worn  by  use  it 
collapses  too  easily  and  the  holes  grow  too  large.  Special  forms  of  nip- 
ples to  "ventilate"  the  bottle  are  not  to  be  recommended,  as  it  is  diffi- 
cult to  keep  them  clean.  Too  long  a  nipple  is  liable  to  press  upon  the 
palate  and  produce  ulceration.  The  nipple  attached  to  a  rubber  tube 
cannot  be  sufficiently  condemned,  as  it  is  almost  impossible  to  keep  the 
tube  clean.     It  is  fortunately  largely  out  of  vogue. 

Cream-dipper. — For  the  purpose  of  obtaining  top-milk  the  most 
satisfactory  method  is  the  employment  of  the  Chapin  dipper.  This  has 
already  been  referred  to  (p.  116). 

Sugar-measure. — The  most  convenient  method  of  measuring  the 
lactose  is  to  employ  the  Chapin  dipper.  While  holding  1  oz.  of  milk, 
it  gives  slightly  less  than  3<2  oz.  (Av.)  of  milk-sugar.  This  fact  must  be 
impressed  upon  the  mother.  Another  way  is  to  employ  a  tablespoon, 
Ijut  this  is  less  satisfactory,  as  the  variation  in  size  is  so  great.  Ap- 
proximately Syi  level  tablespoonfuls,  2  rounded  tablcspoonfuls  or  1} -i 
dipperfuls  of  milk-sugar  is  equivalent  to  1  oz.  Av.  Still  another 
method  is  to  place  1  oz.  of  sugar,  as  determined  by  weighing  it,  in  a  small 
paste  board  box,  level  it,  and  then  cut  off  the  box  at  the  line  of  the  sugar. 


136  THE  DISEASES  OF  CHILDREN 

If  tablcspoonfuls  are  to  be  employed,  the  level  one  is  better,  inasmuch  as 
the  rounded  tablespoonful  gives  more  variation.  Whatever  method  is 
used,  the  sugar  should  be  poured  into  the  measure  until  it  is  over-filled; 
the  holder  tapped  sharply  once  or  twice  on  the  table,  not  more,  and  the 
excess  of  sugar  removed  with  a  case-knife.  Too  long  tapping  settles  the 
sugar  to  too  great  an  extent.  Cane-sugar  and  the  dextrin-maltose  prep- 
arations vary  somewhat  in  weight  from  that  of  lactose,  the  latter  being 
a  trifle  lighter  and  the  former  decidedly  heavier.  Should  it  be  desired  to 
substitute  one  of  them  for  lactose,  it  may  be  roughly  estimated  that  1  oz. 
of  lactose  equals  Syi  level  tablespoonfuls  or  13-^  dipperfuls;  1  oz.  of  a 
dextrin-maltose,  4  level  tablespoonfuls  or  2  dipperfuls;  and  1  oz.  of 
saccharose,  2}^  level  tablespoonfuls  or  1  dipperful.  (For  weight  of 
tablespoonfuls  and  dipperfuls  of  sugar  and  cereal-flours  see  also  p.  153.) 

Glass  Graduate;  etc. — One  of  those  holding  8  fl.oz.,  with  the  first  ounce 
divided  into  drachms,  is  a  great  convenience  in  measuring  the  amounts 
of  fluid  required.  One  of  the  graduated  nursing  bottles  may,  it  is  true, 
be  used  instead,  but  these  are  not  so  accurately  marked. 

In  addition  are  required  a  glass  funnel,  a  bottle-brush,  some  steril- 
ized unabsorbent  cotton  to  make  the  stoppers  for  the  bottles,  pulverized 
boric  acid,  a  bowl  or  pitcher  in  which  to  mix  the  food,  and  a  Freeman 
pasteurizer  described  on  p.  126. 

Regarding  the  ingredients  required,  the  best  milk  possible  is  to  be 
obtained,  running  close  to  4  per  cent,  butter-fat.  (See  Certified  Milk, 
p.  118.)  If  purchased  cream  is  used  it  should  be  separator  cream,  freshly 
obtained,  of  a  guaranteed  percentage-strength  in  fat,  and  with  a  low 
bacterial  content.  Milk-sugar  should  be  purchased  at  least  a  pound  at  a 
time,  as  it  is  cheaper  in  this  way.  The  fact  that  it  is  frequently  impure 
is  not  to  be  forgotten.  If  lime-water  is  employed,  it  may  be  purchased 
or  made  at  home.  In  the  latter  case  a  piece  of  unslaked  lime  the  size 
of  an  egg  is  put  into  a  gallon  of  water,  which  is  then  stirred  vigorously 
and  allowed  to  settle.  The  first  water  is  poured  off  and  fresh  added. 
It  should  be  kept  covered. 

Preparing  and  Giving  the  Food. — First  is  determined  the  number  of 
bottles  which  the  infant  shall  have  in  twenty-four  hours  and  the  number 
of  ounces  at  each  feeding,  the  multiplication  of  one  number  by  the  other 
giving,  of  course,  the  total  amount  required  for  the  day.  All  of  this  is 
to  be  prepared  at  the  one  time,  as  soon  as  possible  after  the  milk  arrives. 
Should  delay  be  unavoidable  the  milk  must  be  kept  on  ice  until  needed. 
The  required  amount  of  sugar  is  then  measured  in  the  manner  described, 
added  to  the  amount  of  water  or  other  diluent  needed  for  the  mixture, 
this  raised  to  the  boiling  point  for  a  moment,  and  then  cooled.  As 
the  addition  of  the  sugar  increases  the  volume  of  the  water  slightly, 
greater  accuracy  may  be  obtained  by  boiling  the  sugar  in  a  portion  of  the 
water  only,  and  then  adding  enough  additional  water  to  bring  the 
volume  up  to  that  of  the  total  amount  of  solution  to  be  added.  The 
difference,  however,  is  not  very  considerable.  The  boihng  of  the 
sugar-solution  is  necessary  only  if  the  mixture  is  to  be  used  raw,  on 
account  of  the  bacterial  content  of  the  sugar  often  existing. 

The  amount  of  top-milk,  cream,  whole-milk,  skimmed  milk,  and  water 
— as  the  case  may  be — is  now  measured  and  added  to  the  sugar-solu- 
tion and  all  the  ingredients  mixed  well,  the  volume  of  the  whole  equalling 
the  amount  of  food  desired  for  twenty-four  hours.  Should  it  be  intended 
to  sterilize  the  mixture  at  212°F.  (100°C.)  and  the  use  of  hme-water  be 
desired,  this  should  not  be  added  until  the  process  is  over.     With  pas- 


ARTICLES  REQUIRED  7.V  PREPARING  THE  FOOD 


137 


teurizing  at  140°  to  150°F.  (60°  to  6o.5°C.)  there  is  no  such  necessity, 
inasmuch  as  the  hme-water  is  not  affected  by  this  temperature.  Into 
each  bottle  is  now  poured  the  amount  for  each  feeding,  and  the  neck  of 
the  bottle  wiped  clean  and  dry  and  then  stoppered  with  a  cotton-plug. 
The  bottles  are  now  put  into  the  pasteurizer  and  the  food  pasteurized, 
if  this  is  desired,  cooled,  and  kept  on  ice.  When  a  bottle  of  food  is 
needed,  and  then  only,  it  is  removed  from  the  ice,  and  placed  in  a  tin 
of  cool  water;  and  this  is  then  warmed  until  the  milk  is  at  98  to  100°F. 
(36.7°  to  37.8°C.),  but  not  more.  This  is  determined  by  a  thermometer 
made  for  the  purpose  and  placed  in  the  milk-bottle,  not  in  the  water 
(Fig.  22).  If  the  bottle  is  plunged  directly  into  hot  water  the  glass  is 
liable  to  crack.  The  nipple  is  now  put  on  and  the 
child  fed.  In  heating  the  food  a  tin  sufficiently 
tall  should  be  employed  to  allow  the  water  to 
cover  the  bottles  to  the  neck,  but  narrow  enough 
to  reduce  to  a  minimum  the  actual  amount  of 
water  required  (Fig.  22).  Placed  upon  a  small 
alcohol  heater  or  gas-stove,  the  water  and  bottle 
of  milk  will  thus  be  raised  quite  rapidly  to  the 
required  temperature.  This  rapidity  is  an  im- 
portant matter  when  a  hungry  child  is  crying 
impatiently  for  food. 

As  with  breast-feeding,  regularity  in  the  hours 
for  food  must  be  followed.  The  child  should 
empty  its  bottle  in  from  10  to  20  minutes,  and 
should  not  be  allowed  to  suck  at  it  indefinitely  or 
to  go  to  sleep  until  it  has  finished  its  meal.  Any 
milk  left  over  must  be  thrown  away  at  once; 
never  warmed  up  and  given  again  later.  The 
bottle  should  be  held  by  the  hand  so  that  its 
neck  is  always  full  of  milk.  It  should  be  drawn 
from  the  mouth  from  time  to  time  to  allow  air 
to  enter  through  the  nipple  in  order  to  keep  this 
from  collapsing.  The  child  should  be  held  in  the  lap  or  in  the  arms 
while  being  fed.  It  is  a  bad  plan  to  prop  the  bottle  up  with  pillows  to 
enable  the  infant  to  suck  while  it  is  in  bed.  After  being  used  the  bottle 
should  be  at  once  washed  with  a  strong  solution  of  washing  soda,  scrub- 
bed with  a  bottle-brush,  and  rinsed  out  well  with  pure  water.  Shortly 
before  they  are  filled  all  the  bottles  should  be  boiled  at  one  time.  The 
nipples  should  be  scrubbed  thoroughly  without  and,  after  turning  inside 
out,  within,  and  afterward  be  kept  submerged  in  water  or  in  a  boric  acid 
solution  until  needed.  Before  using  it  is  well  to  plunge  them  for  a 
moment  in  boiling  water. 

The  Calculation  of  the  Milk=formulaB. — In  employing  home- 
modification,  milk-mixtures  ma}^  be  made  either  (1)  from  a  combination 
of  whole-milk  and  cream  of  a  definite  known  strength,  or  (2)  from  dilu- 
tions of  whole  milk,  top-milk  or  skimmed  milk.  The  pages  which  follow 
are  for  the  guidance  of  those  readers  prepared  to  take  for  themselves  an 
active  interest  in  the  calculation  of  the  amounts  of  the  different  elements 
required  in  the  food.  For  those. who  would  prefer  to  avoid  the  trouble, 
the  table  given  on  p.  142  may  be  found  a  useful  guide.  A'aiiou.s 
methods  of  computing  the  percentages  have  been  proposed;  none  of  them 
giving  other  than  approximately  accurate  results,  but  near  enougii  fur 
practical  purposes. 


Fid.    22. — Milk-bot- 
tle,   Heating    Tix, 
Thermometer. 


AND 


138  THE  DISEASES  OF  CHILDREN 

1,  Whole-milk-and-cream  Mixtures. — This  was  almost  the  only 
method  employed  for  home-modification  some  years  ago,  but  it  has 
since  given  place  almost  entirely  to  top-milk  mixtures.  It  is  explained 
here  because  still  in  use  by  some  physicians  or  in  some  hospitals;  and  be- 
cause it  has  distinct  advantages  in  occasional  instances.  It  is  apphcable 
only  when  a  cream  of  definitely  known  strength  can  be  obtained.  The 
simplest  method  of  determining  the  amount  of  whole-milk  and  of  cream 
required  is  that  proposed  by  Baner.  ^  We  need  not  go  into  the  derivation 
of  his  equations,  but  the  calculation  is  as  follows: 

Let  Q    =  the  total  quantity  of  food  needed  for  24  hours. 

F    =  the  percentage  of  fat  desired  in  the  mixture. 
P    =  the  percentage  of  protein  desired  in  the  mixture. 
S    =  the  percentage  of  sugar  desired  in  the  mixture. 
C    =  the  amount  of  cream  to  be  used  in  the  mixture. 
CF  =  the  percentage-strength  of  the  cream  in  fat. 
L    =  the  amount  of  sugar  (lactose)  to  be  added  to  the  mixture. 
W  =  the  amount  of  water  to  be  added  to  the  mixture. 

Then     (I)  C.    =  ^y^zr^  X  {F  -  P). 

(II)  M.  =  ^^  -  C. 

(III)  W.  =Q  -  (M  +  C). 

(IV)  L.     -  jQQ 

The  denominator  of  equation  (I)  is  always  the  percentage-strength  of 
the  cream  in  fat,  minus  4. 

As  an  example  of  the  use  of  the  formulae,  suppose  it  is  desired  to  give 
an  infant  8  bottles  of  4  oz.  each,  making  a  daily  quantity  of  32  oz.;  that 
this  shall  contain  fat  3  per  cent.,  sugar  6  per  cent,  and  protein  1.5  per 
cent.,  and  that  the  cream  is  of  20  per  cent,  fat-strength. 

If  we  substitute  these  figures  in  the  equations  these  read: 

32  X  (3  -  1.50)       32  X  1-.5       „    .       „       „        ^„  , 

(I)        C.    = ^A — T =  7^ —  =  3;  I.e.  C  =  3  oz.  20  per  cent,  cream. 

(II)  M.  =  ^^J^A-^  -3=9;  i.e.  M.  =  9oz.  whole  milk. 

(III)  IT.  =  32  -  (9  +  3)  =  20  oz.  water. 

,„,,  ,         32  X  (6  -  1.50)        ,  .-     .  ,11     1  r 

(IV)  L.  = Y^ =  1.44;  i.e.  practically  1.5  oz.  sugar. 

Should  Equation  II  result  in  O,  it  would  mean  that  no  milk,  but  only 
cream  of  the  strength  indicated,  is  to  be  used  in  making  the  mixture. 
Resulting  in  a  minus  quantity  it  denotes  that  the  formula  desired  cannot 
be  constructed  with  the  strength  of  cream  employed,  and  that  one  with 
a  higher  percentage  of  fat  must  be  selected.  When  it  is  necessary  to 
employ  a  milk  containing  5  per  cent,  of  fat,  the  figures  may  be  reduced  to 
4  per  cent,  by  dipping  off  and  discarding  the  top  2  ounces  of  the  quart 
after  the  cream  has  separated,  and  then  shaking  up  the  bottle  well 
before  the  remaining  milk  is  used  as  "  whole  milk." 

The  criticism  may  properly  be  made  that  Baner's  formulae  are  inaccu- 
rate, since  they  assume  that  milk  and  cream  each  contain  4  per  cent,  of 
protein,  whereas  milk  more  often  has  3.5  per  cent.,  and  cream  has  some- 

1  New  York  Med.  Jour.,  1898,  Mar.  12,  345. 


ARTICLES  REQUIRED  IN  PREPARING  THE  FOOD 


139 


what  less  sugar  and  protein  than  has  whole  milk.  A  comparison  of  the 
real  and  the  calculated  protein-percentages  obtained  shows,  however, 
differences  which  are  entirely  negligible.  It  is  only  when  employing 
milk-mixtures  containing  as  much  as  3  per  cent,  of  protein  that  the  differ- 
ence between  the  calculated  and  the  actual  protein  amounts  present 
reaches  as  much  as  somewhat  less  than  0.5  per  cent. 

2.  Top-milk,  Skimmed-milk  and  Whole-milk  mixtures. — In  recent 
years  the  dilution  of  top-milk,  whole-milk  or  skimmed-milk  has  become 
the  popular  method  of  preparing  the  food.  It  offers  every  advantage 
in  convenience  and  in  reasonably  approximate  accuracy  in  the  percentages 
present.  Many  figures  have  been  given  by  different  investigators  of  the 
strengths  of  varying  numbers  ,of  ounces  of  the  milk  in  a  quart  milk- jar. 
They  are  close  enough  to  show  that  this  method  of  feeding  can  be  em- 
ployed satisfactorily.  With  the  exception  of  the  fat,  the  average  infant 
can,  as  a  rule,  tolerate  decided  variations  in  the  milk-elements;  and  the 
important  matter  after  all,  as  has  been  stated  previously,  is  not  so  much 
the  initial  accuracy  of  the  percentages  as  it  is  the  comparative  accuracy 
of  the  changes  in  the  food  which  it  may  be  desired  to  make  from  time  to 
time. 

With  this  in  mind,  and  aware  especially  of  the  importance  of  rendering 
the  calculating  as  simple  and  as  comprehensible  as  possible,  I  have  for  a 
number  of  years  followed  and  taught  the  following  plan.  The  percent- 
ages are  based  upon  the  published  figures  of  different  observers  and  upon 
unpublished  investigations  made  at  my  suggestion  by  Dr.  Charles  A. 
Fife.  The  percentages  of  protein  and  of  sugar  have  intentionally  been 
slightly  distorted  for  reasons  presentl}^  to  be  given.  The  title  "  skimmed- 
milk"  designates  any  milk  from  which  all  or  a  portion  of  the  cream  has 
been  removed.     (See  p.  117.) 

Table  45. — Percentage-strengths  of  Top-milk  and  Skijimed-milk  Layers 
Milk  obtained  from  a  quart  of  4  per  cent,  milk  by  dipping,  as  previous!}^  described 
(p.  116),  gives: 


Upper   2  oz 

Upper    4  oz 

Upper    6  oz 

Upper    8  oz 

Upper  10  oz 

Upper  16  oz 

Upper  20  oz 

Upper  24  oz 

Upper  32  oz.  (whole-milk) 

Lower  .30  oz 

Lower  28  oz 

Lower  16  oz 

Lower    8  oz 


Fat,  per  cent. 


Protein  and 
sugar,  per  cent. 


24.0 

20.0 

16.0 

12.0 

10.0 

8.0 

6.0 

5.0 

4.0 

3.0 

2.0 

1.0 

0.5 


Approximate 
ratio 


.6 

.5 

.4 

.3 

2.5 

.2 

1.5 

1.25 

.1 
0.75 
0.50 
0.25 
0.0 


to 

to 
to 
to 
to 
to 
to 
to  1 
to  1 
to  1 
to  1 
to  1 
to  1' 


This  table  applies  to  milk  containing  approximately  4  per  cent,  of  fat. 
With  rich  milk,  showing  5  per  cent,  of  fat,  all  that  is  necessary  is  to  remove 
and  discard  the  top  2  oz.  and  then  to  proceed  with  the  dipping  as  though 
this  had  not  been  done.  That  is  to  say,  by  the  "top  8  oz.,"  for  example, 
is  indicated  the  upper  8  oz.  remaining  after  the  top  2  oz.  have  been  dis- 

' The  amount  of  fat  in  the  lower  8  oz.  is  so  small  that  it  may  bo  ignored  in  the 
"approximate  ratio." 


140  THE  DISEASES  OF  CHILDREN 

carded.  The  figures  in  the  table  are  not  absolutely  accurate,  and  are  not 
intended  to  be.  They  are  sufficiently  so  for  practical  purposes,  and  the 
discrepancy  is  slight  as  compared  with  the  great  convenience  in  applica- 
tion. As  previously  shown,  the  protein  of  whole  milk  is  nearer  3.5  than 
4  per  cent.,  and  is  even  slightly  less  than  this  in  the  top-milk  usually 
employed ;  but  the  difference  after  the  required  dilution  has  taken  place 
is  so  slight  that  it  is  negligible.  This  statement  applies  equally  well  to 
the  difference  between  the  adopted  4  per  cent,  of  sugar  and  the  actual 
4.5  per  cent.,  and  to  the  fact  that  the  upper  16  oz.  is  more  properly 
stated  as  containing  from  7  to  7.5  per  cent.  fat.  The  great  convenience  of 
the  approximate  ratios  which  the  table  shows  quite  justifies  the  slight 
distortion  of  the  figures.  It  is  only  when  high  protein-percentages 
are  used  that  the  discrepancy  in  the  percentages  is  to  be  considered — a 
calculated  protein-strength  of  3  per  cent,  in  the  mixture  showing  a  de- 
ficiency of  not  quite  0.5  per  cent.  If  one  bears  in  mind  the  protein-needs 
of  the  infant  (pp.  50  and  130)  it  is  easy  to  determine  whether  the  defi- 
ciency is  one  which  must  be  considered.  This  will  not  be  necessary  unless 
the  minimum  requirement  is  being  closely  approached,  and  this,  of 
course,  will  not  happen  when  high  protein  mixtures  are  being  employed. 
In  employing  the  table  we  can  conveniently  follow  the  common  cus- 
tom of  making  a  20-oz.  mixture  our  basis.  Should  we  need,  for  in- 
stance, 36  oz.,  twice  the  20  oz.  may  be  prepared,  and  the  extra  4  ounces 
discarded;  if  30  oz.  is  required,  1^^  times  the  20  oz.  is  made.  It  is  to 
be  noted  first  of  all  that  the  percentages  of  protein  and  of  sugar  are  the 
same.  Whatever  percentage  we  deduce  for  the  former  will  be  equalled 
by  the  latter.  Our  first  step  is  to  determine  what  percentages  of 
fat,  sugar  and  protein  are  wanted  in  the  milk-mixture.  Suppose,  for 
instance,  that  we  desire  one  of  fat  3  per  cent.,  sugar  6  per  cent,  and 
protein  1  per  cent.  The  ratio  of  fat  to  protein  is  that  of  3  to  1.  In 
consulting  the  table  it  will  be  seen  that  the  upper  8  oz.  containing 
12  per  cent,  of  fat  possesses  this  ratio,  and  is  the  proper  one  to  use.  Now 
it  is  evident  that  if  20  oz.  of  milk  contain  12  per  cent,  of  fat,  and  we 
wish  to  reduce  it  to  3  per  cent.,  i.e.,  ^i,  we  merely  divide  the  20  by  4, 
and  make  up  the  rest  with  water,  i.e.,  we  use  5  oz.  of  the  upper 
8  oz.,  and  15  oz.  of  water.  This  may  be  expressed  in  an  equation, 
to  which  reference  will  be  made  from  time  to  time  as  the  basic  equation. 

BASIC  EQUATION  TO  OBTAIN  THE  DESIRED  FAT-PERCENTAGE 

Total  quantity  of  food  X  Percentage  of  fat  desired  ^  Quantity  of  top-milk  or 

Fat-strength  of  the  milk  used  ~    skimmed-milk  in  the  mixture. 

Applying  this  to  the  milk-mixture  in  question  the  equation  reads: 

20  X  3 

—  -- —  =  5  oz.  of  upper  8  oz.  in  a  20  oz.  mixture. 

The  calculation  for  the  dilution  to  obtain  the  fat-percentage  is  the 
only  one  required,  for  the  desired  dilution  of  the  protein  follows  auto- 
matically, and  the  original  4  per  cent,  is  reduced  to  1  per  cent.  The  sugar 
has  been  cut  down  to  the  same  amount,  since  the  percentages  of  the  two 
are  always  the  same.  Wishing  however,  to  have  the  sugar  in  the  mixture 
6  per  cent.,  it  is  clear  that  since  1  per  cent,  is  already  present,  we  need  only 
to  add  5  per  cent.;  i.e.  20  X  0.05  =  1  ounce  of  sugar  to  be  added  to  the 
20  oz.  mixture.     Our  milk-formula  will  then  read : 

Upper  8  oz.,  5  oz. 
Milk-sugar,  1  oz. 
Water  to  make  20  oz. 


BASIC  EQUATION  TO  OBTAIN  THE  DESIRED  FAT-PERCENTAGE     141 

Very  frequently  a  weak  cereal-decoction  is  employed  as  a  diluent.     This 

naturally  increases  the  total  carbohydrate-percentage  in  the  mixture;  but 

as  a  rule  this  may  be  ignored,  and  account  taken  of  the  sugar  only. 

Should,  however,  one  wish  to  allow  for  the  difference,  and  to  add,  say, 

1  per  cent,  of  starch,  reducing  the  sugar-addition  to  4  per  cent.,  we  may 

make  a  decoction  of  1.80  per  cent,  of  starch  (see  p.  154),  and  again  apply 

the  equation  just  given,  the  starch  replacing' the  fat  in  it.     This  reads: 

20  X  1 

— Y  j,pj—  =  approximately  11    oz.,  indicating  that   this   amount  of  the 

cereal  decoction  is  to  be  used  in  place  of  an  equal  number  of  ounces  of 
water  to  make  a  20  oz.  mixture.     The  formula  would  then  read : 

Upper  8  oz.,  5  oz. 

Sugar,  0.8  oz.  (i.e.  4  per  cent,  of  20  oz.). 

Barley-water,  11  oz. 

Water  to  make  20  oz. 

Generally,  however,  such  a  refinement  of  calculation  is  not  necessary. 

One  more  example  may  be  given.  Let  us  suppose  that  we  desire  to 
make  the  protein-percentage  in  the  mixture  given  2  per  cent,  instead  of 

1  per  cent.;  viz.  fat  3  per  cent.,  sugar  6  per  cent.,  protein  2  per  cent. — 

a  ratio  of  3  to  2,  with  the  sugar  6  per  cent,  as  before.     Two  courses  are 

open  to  us.     First,  and  most  simply,  we  can  select  the  upper  20  oz. 

of  the  quart,  containing  6  per  cent,  of  fat  and  4  per  cent,  of  sugar — a  ratio 

of  3  to  2,  or  13^^  to  1,  as  shown  in  the  table.     Using  the  same  basic  equation 

20  X  3 
to  obtain  the  percentage  of  fat,  we  have  — ^ —  =  10  oz.  of  the  top 

20   oz.    of   the   quart   required   in   the   20   oz.    mixture.     The   propor- 
tions of  protein  and  of  sugar  have  automatically  become  2  per  cent.,  the 
ratio  of  3  to  2  holding  good.     The  other  course  is  as  follows: 
Using,  for  instance,  the  upper  8  oz.  as  in  the  first  example  we  derive  the 
mixture: 

Upper  8  oz.,  5. 

Water,  15., 

giving  fat  3  per  cent.,  protein  1  per  cent.  To  increase  the  protein 
to  2  per  cent,  without  affecting  the  fat,  it  is  only  necessary  to  add  a 
sufficient  amount  of  milk  in  which  the  fat  is  a  negligible  quantity,  as  in 
the  bottom  8  oz.  of  the  quart.  If  this  contains  4  per  cent,  of  protein,  it  is 
evident  that  j-i  of  the  20  oz.  would  contain  1  per  cent,  of  protein.  That 
is  to  say,  by  adding  5  oz.  of  skimmed-milk  to  the  mixture  in  place  of 
5  oz.  of  water  we  shall  have  increased  the  protein-percentage  from  1  per 
cent,  to  2  per  cent.     Our  milk-formula  would  then  read: 

Upper  8  oz.,  5  oz. 
Lower  8  oz.,  5  oz. 
Water,  10  oz. 

Having  2  per  cent,  of  protein  in  the  mixture  we  necessarily  have  2  per 
cent,  of  sugar,  and  all  that  is  required  to  obtain  the  desired  6  per  cent,  of 
sugar  is  to  add  the  additional  4  per  cent.;  i.e.  20  X  0.04  =  0.8  oz. 

If  a  quantity  of  food  is  required  which  calls,  for  instance,  for  10  oz. 
of  the  upper  8  oz.,  it  is,  of  course,  necessary  to  take  8  oz.  from  each  of 

2  quarts,  or  8  oz.  from  a  quart  and  4  oz.  from  a  pint,  mix  them  and  use  10 
oz.  of  the  mixture. 

Where  mixtures  are  desired  in  which  the  protein-percentage  is  in 
excess  of   the  fat-i)ercentage;    i.e.  skinuned  milk  mi.xttires,  the  method 


142 


THE  DISEASES  OF  CHILDREN 


of  procedure  is,  of  course,  the  same,  using  only  the  lower  layers  in  the 

table  in  place  of  the  upper.     Thus  for  a  mixture  of  fat  1  per  cent,  and 

protein  2  per  cent.,  we  can  employ  the  lower  28  oz.,  containing  2  per  cent. 

of  fat,  and  having  the  ratio  of  0.5  to  1.     Our  equation  for  the  fat  gives  us 

20  X  1 

— ^—  =  10  oz.  of  the  lower  28  oz.  required  in  a  20  oz.  mixture,  this 

naturally  reducing  the  2  per  cent,  of  fat  and  4  per  cent,  of  protein  to  1  per 
cent,  of  fat  and  2  per  cent,  of  protein  respectively. 

In  the  cases  where  it  is  desired  that  the  percentages  of  fat  and  of 
protein  shall  be  approximately  equal,  whole-milk  may  well  be  employed. 
If,  for  instance,  a  formula  of  fat  2.5  per  cent.,  sugar  5  per  cent.,  and  pro- 


Ready  Method  for  Selecting 
Ainoiuits  to  be  Employed  in  Making  Varioas  20-Oz.  Miik-Mixtores,  and  the  Caloric  Valaes  Resulting 

Percentages 
desired  of 

Lower 
Sot. 

Low- 
er 
16  oz. 

low- 
er 
28  oz. 

Whole 
MUk 

Up- 
per 
24  oz. 

Up- 
per 
20  oz. 

Up. 
per 
16  oz. 

Up- 
per 
10  oz. 

Up. 
per 
So;;. 

Water 
oz. 

Sugar 
oz. 

Caloric 
Value  of 
Mixture 

Caloriea 
per  01. 

Fat 

SuKar 

Prot'n 

0.5 

5 

1 

5 

15 

0.8 

175 

8.75 

0.5 

6 

2 

10 

10 

0.8 

225 

11.25 

1 

6 

1 

5 

.  . 

15 

1 

225 

11.25 

1 

6 

1.5 

2.5 

5 

12.5 

0.9 

237.5 

11.88 

1 

6 

2 

10 

10 

0.8 

250 

12.5 

1.5 

6 

1 

5 

15 

1 

250 

12.5 

1.5 

6 

1.5 

7.5 

12.5 

0.9 

262.5 

13.13 

2 

6 

1.5 

2.5 

5 

12.5 

0.9 

287.5 

14.38 

2 

6 

2 

10 

10 

0.8 

300 

15 

2.5 

6 

1.5 

2.5 

5 

12.5 

0.9 

312.5 

15.63 

2.5 

6 

2 

10 

10 

0.8 

325 

16.25 

2.5 

6 

2.5 

12.5 

7.5 

0.7 

337.5 

16.88 

3 

6 

1 

5 

15 

1 

325 

16.25 

3 

6 

1.5 

2.5 

5 

12.5 

0.9 

337.5 

16.88 

3 

6 

2 

10 

10 

0.8 

350 

17.5 

3 

6 

3 

15 

6 

0.4 

375 

18.75 

4 

4 

4 

20 

0 

400 

20 

Fig.  23. — Author's  Milk-card. 
Showing  amount  of  different  layers  to  be  used  for  the  preparation  of  various  per- 
centage-mixtures, and  the  caloric  values  of  the  mixtures.      {Griffith,  Journ.  Amer.  Med. 
Assoc,  1918,  LXXI,  441.) 

tein  2.5  per  cent,  is  desired,  we  substitute  in  the  basic  equation  the  per- 
centage values  of  whole-milk  as  given  in  the  table  (p.  139)  as  follows: 

?0.><A^  =  12.5  ounces  whole-milk  in  the  20  oz.  mixture.     As  this  gives 

4 
us  necessarily  also  2.5  per  cent,  of  protein  and  2.5  per  cent,  of  sugar, 
the  addition  of  2.5  per  cent,  of  sugar  is  obtained  as  before;  i.e.  20  X 
0.025  =  0.5  oz.  of  sugar  to  be  added. 

The  whole  matter  of  calculation  will  be  found  extremely  simple  upon 
trial.     It  may  be  summarized  in  the  following  three  rules: 

1.  Select  the  top,  skimmed  or  whole  milk  which  possesses  the  ratio  of  fat 
to  protein  desired  for  the  mixture  (Table  45,  p.  139). 

2.  By  using  the  equation  on  p.  140,  calculate  the  amount  of  this  milk 
needed  in  a  20  oz.  mixture  to  give  the  desired  fat-percentage.  The  results 
will  give  the  desired  protein-percentage  also. 

3.  The  sugar  having  been,  of  course,  reduced  equally  with  the  protein, 
add  as  much  more  to  the  20  oz.  as  is  needed  to  raise  it  to  the  desired  percentage. 


BASIC  EQUATION  TO  OBTAIN  THE  DESIRED  FAT-PERCENTAGE     143 

The  figures  in  the  table  (p.  139)  run  so  easily  in  sequence  that  they  are 
carried  in  mind  without  effort,  and  a  little  consideration  will  reveal  many 
possibihties  of  producing  the  same  results  by  different  methods.  Thus  a 
formula,  calhng  for  3  per  cent,  of  fat  and  2  per  cent,  of  protein  can  be 
made,  as  already  shown  (p.  Ml),  either  by  diluting  10  oz.  of  the  upper  20 
oz.  of  the  quart  with  10  oz.  of  water,  or  by  mixing  5  oz.  of  the  top  8  oz. 
with  5  oz.  of  the  bottom,  and  adding  10  oz.  of  water.  One  requiring  2  per 
cent,  of  fat  and  1  per  cent,  of  protein  may  consist  of  5  oz.  of  the  top  16  oz. 
of  the  quart  and  15  oz.  of  water;  or  of  3li  oz.  of  the  top  8  oz.,  1^^  oz. 
of  the  bottom,  and  15  oz.  of  water.  One  calhng  for  2  per  cent,  of  fat  and 
2  per  cent,  of  protein  may  be  constructed  simply  by  diluting  whole- 
milk  with  an  equal  amount  of  water,  or  by  mixing  4  oz.  of  the  top  10  oz. 
with  6  oz.  of  the  bottom  8  oz.  and  10  oz.  of  water.     In  each  case  the 


Table  Giving  Approximate  Percentage- 
Strengths  of  Different  Layers  of  Milk 


tJjjper 


Lower 


Per 

Per  cent. 

cent. 

Protein 

Ratio 

•Fat 

and  Sugar 

2oz 

..24 

4 

6to  1 

4  " 

..20 

4 

5to  1 

6  " 

..16 

A 

4  to  1 

«  " 

..12 

4 

3tol 

10  " 

..10 

4 

2.5  to  1 

16   " 

..   8 

4 
4 

2  to  1 

20   " 

..  6 

1.5  to  1 

24   " 

.   ,5 

4 

1.25  to  1 

32   '• 

/  whole  \  . 
\milk    /  * 

4 

1  tol 

30  •' 

..   3 

4 

.75  to  1 

m  " 

..   2 

4 

4 
4 

.50  to  1 

ifi- " 

..    1 

.25  to  1 

8  " 

..  0.5 

.Oto  1 

To  Find  the  Amount  of  Any  Layer  of  Milk  to  be  Used 
to  Give  Percentages  Desired 

Equation:  - 

Total  amount  of  food  X  Percentage  of  fat  desired 


Fat-8trengtt  of  layer  of  milk  used 


Amount  of 
thia  milk  in 
the  mixture. 


(1)  Select  from  the  "Layers  of  Millf"  Table  the  milk  which 
possesses  the  desired  ratio  of  fat  to  protein. 

(2)  Substitute  in  the  equation. 

(3)  As  the  sugar-percentage  has  been  reduced  equally  with 
that  of  the  protein,  add  sufScient  sugar  to  raise  to  the 
desired  percentage. 

Example:  20-oj.  mixture  desired.  Percentages  desired  =  Fat  3, 
Sugar  6,  Protein Jl.     Use  upper  8  oz.  (fat  12%,  protein  4%, 

20X3 
viz:  3  :  1).     Then  =5  oz.  of  upper  8  oz.,  with  15  ox. 

of  water  in  the  20-oz.  mixture.  The  protein  necessarily 
becomes  1%,  and  the  sugar  likewise.  The  mixture  already 
containing  !•%  of  sugar,  add  5%  of  20  oz.,  i.  e.,  1  oz.  of 
sugar  to  increase  this  to  the  6%  desired. 


To  Determine  the  Percentages  Present  in  Any  Milk-Mixture  Already  in  Use 

Quantity  of  substance  used  (milk,  cream,  or  skimmed  milk)  Xlts  percentage-strength  _  Percentage  of  element  (P., 

Total  Quantity  of  Food  ~  S.  or  P.)   in   the  mixture. 

Example:   The  mother  has  mixed:    Upper  8  oz.;   6  oz. — Lower  8  oz.;  3  oz. — Milk-sugar  3  level  tablespoonfuls.— 

Water  27  oz.    Total  quantity  =36  oz.    The  upper  8  oz.  contains  12%  fat  (see  Table).    Both  top  and  bottom 

milk  contain  4%  protein  and  sugar.    Three  taolespoonfuls  sugar  =  approximately  1  oz.    The  fat  of  the  lower 

6X12  3X0 

8  oz.  may  be  ignored.     Then     „„     =2  =Fat  percentage  from  the  top-milk.      _,    =0=Fat-percentage  from 
oo  3o 

9X4 
the  bottom  milk.     -53-  =  1  =  Protein  and  sugar  percentages  from  combined  top  and  bottom  milk.     The 

3d 
1  oz.  additional  sugar  divided  by  36  ^approximately  3%  sugar  added.    Tliere  being  already  1%  sugar 
derived  from  the  milk,  the  total  sugar  —i%. 


Fig.  24. — Author's  Milk-card. 
Reverse  side  of  Fig.  23,  showing  the  percentages  in  different  layers  of  milk;  the  calcula- 
tion of  the  amount  to  be  used  for  any  formula  desired,  and  the  calculation  of  the  percentages 
in  any  mixture  already  in  use.     {Griffith,  Journ.  Aincr.  Med.  Assoc,  1918,  LXXI,  441.) 


requisite  percentage  of  sugar  must  be  added.  The  simplest  way  is 
usually  the  best,  both  for  the  physician  and  for  the  mother  or  nurse. 

For  ready  reference,  those  who  desire  to  avoid  all  calculation  as 
far  as  possible  may  employ  the  table  shown  in  Fig.  23.  This  is 
based  on  the  percentage-strengths  as  given  on  p.  139.  Fraley's  formula 
has  been  used  for  the  determination  of  the  caloric  values.  (See  p.  123.) 
The  milk-mixtures  selected  are  those  most  Ukely  to  be  found  useful.  The 
employment  of  fractional  percentages  smaller  than  those  given  offers  no 
practical  advantage. 

To  Ascertain  the  Percentages  Present  in  any  Milk-mi.\ture. — 
Inasmuch  as  the  description  of  the  food  in  use  is  always  given  by  the 
mother  in  terms  of  milk,  cream,  top-milk,  water,  etc.,  it  is  important  to  be 
able  readily  to  ascertain  what  percentages  of  the  milk-elements  the  child 
is  actually  receiving,  in  order  to  determine  whether  any  ingretliont  is 


144  THE  DISEASES  OF  CHILDREN 

manifestlj'  present  in  incorrect  proportion  and  is  probably  at  fault  if 
symptoms  of  indigestion  exist. 

The  procedure  is  simple.  To  calculate  the  total  percentage  of  any 
of  the  milk-elements  present  in  the  mixture,  multiply  the  quantity  of 
the  substance  (milk,  cream,  etc.)  containing  it  by  the  percentage  of 
the  element  present  in  this,  and  divide  by  the  total  number  of  ounces 
of  the  mixture.     In  the  form  of  an  equation  it  would  read: 

Quantity  of  substance         ^  j.  .  .         ,, 

^used  (milk,  cream,  etc.)  ><  ^^s  percentage-strength  ^  p^^^^^^^^^  ^j  ingredient    in 

Total  quantity  of  food  the  mixture. 

This  is  emplo3^ed  to  determine  both  the  fat-percentage  and  that  of  the 
protein  and  sugar.  Supposing,  for  instance,  we  are  told  that  the  infant 
has  been  receiving  a  mixture  of: 

Upper  8  oz.  of  a  quart,  6  oz. 
Lower  8  oz.  of  a  quart,  3  oz. 
Sugar,  3  rounded  tablespoonfuls. 
Barley-water,  27  oz. 

making  a  total  food-mixture  of  36  oz.,  containing  a  total  of  9  oz.  of  milk 
in  all.  We  are  told  that  the  barley-water  is  made  by  cooking  2  level 
tablespoonfuls  of  barley  in  1  quart  of  water,  and  replacing  the  water  which 
has  been  boiled  away.  Using  now  the  Table  of  Percentage  Strengths, 
p.  139,  with  the  same  restrictions  as  to  accuracy  as  explained  regarding  it, 
we  have  in  the  upper  8  oz.,  fat  12  per  cent.,  protein  and  sugar  each  4  per 
cent.;  in  the  lower  8  oz.,  fat  practicall}^  0  per  cent.,  protein  and  sugar 
each  4  per  cent.  The  3  rounded  tablespoonfuls  of  sugar  are  equivalent  to 
13^^  oz.  (pp.  135,  153).  The  barley-water  gives  a  percentage  of  1.20  of 
starch  (see  table  51,  p.  154).  Substituting  these  various  values  in  the 
equation  the  figures  are  as  follows : 


=  2         Fat  per  cent,  obtained  from  the  top-milk. 
=  0         Fat  per  cent,  obtained  from  the  bottom-milk. 


6  X  12 

36 

3X0 

36 

9  X  4  _  Per  cent,  of  protein  obtained  from  the  combined  top-  and  bot- 

36      ~  tom-milks  (6  +  3). 

9  X  4  _  Per  cent,  of  carbohydrate  obtained  from  the  combined  top-  and 

36~  ""  bottom-milks. 


27  X  1.20 
36 


=  0.9     Per  cent,  of  carbohydrate  obtained  from  the  barlev-water. 


Besides  this  we  have  added  1.5  oz.  of  extra  sugar  to  the  36  oz.  of  mixture; 
and  dividing  the  1.5  by  36  this  furnishes  a  percentage-addition  of  approxi- 
mately 4  per  cent.,  which,  with  the  sugar  already  present,  and  the  carbo- 
hydrate of  the  barley-water,  gives  a  total  carbohydrate-percentage  of 
about  6  per  cent.  The  food  is  thus  found  to  contain  fat  2  per  cent.; 
carbohydrates  6  per  cent. ;  protein  1  per  cent. 

For  the  convenience  of  my  students  I  had  the  table  for  the  ready 
method  of  the  preparation  of  milk-mixtures  printed  in  pocket-card  form 
(Fig.  23),  and  upon  the  reverse  side  (Fig.  24),  the  table  for  layer-milk 
(p.  139)  and  the  various  matters  relating  to  the  calculation  of  formulae  as 
already  described.^ 

^  These  cards  may  be  obtained  from  Edward  Pennock,  3609  Woodland  Ave., 
Phila.,  at  a  cost  of  6  cents. 


BASIC  EQUATION  TO  OBTAIN  THE  DESIRED  FAT-PERCENTAGE     145 

Whey. — This  consists  of  milk  from  which  the  casein  has  been  re- 
moved by  the  use  of  rennet  although  the  lactalbumin  remains.  The 
amount  of  fat  is  diminished  very  greatly,  being  entangled  in  the  curd 
which  the  rennet  produces.  Whey  is  prepared  as  follows:  Into  a  quart 
of  warm,  fresh  milk,  heated  to  100°F.  (37.8°C.)  are  stirred  2  teaspoon- 
fuls  of  liquid  rennet  or  of  essence  of  pepsin.  After  coagulation  has  taken 
place  the  milk  is  placed  in  the  cold  for  about  3^^  hour,  the  curd  then 
broken  up  with  a  fork  in  order  to  hberate  the  whey,  and  the  latter  strained 
through  cheese-cloth  or  musUn  without  pressure.  There  will  be  obtained 
from  1  to  13-^  pints  of  whey.  The  finer-meshed  and  thicker  the  cloth 
the  more  fat  will  be  removed  by  it.  When  it  is  desired  to  produce  a 
whey  containing  practically  no  fat,  a  fat-free,  separator  milk  or  the  milk 
from  a  quart  jar  after  the  cream  has  been  removed  should  be  employed 
instead  of  whole-milk.  Failure  to  coagulate  firml}^  indicates  that  not 
enough  rennet  was  used  or  that  the  milk  had  been  boiled  previously  or 
was  too  cold.  If  whey  is  to  be  mixed  later  with  milk  or  cream,  the  rennin 
remaining  in  it  must  be  destroyed  by  heating  it  for  some  time  to  a  tem- 
perature of  140°F.  (60°C.)  or  over  (pasteurizing),  otherwise  the  casein  of 
the  cream  will  coagulate.  If  it  is  heated  to  7o°C.  (167°F.)  coagulation  of 
the  lactalbumin  begins.  Various  analyses  of  whey  have  been  made. 
The  average  of  many  of  them,  according  to  the  figures  given  by  Konig,^ 
is  as  follows: 

T.\BLE  46. — Composition'  of  Whby  (Konig) 

Fat 0.32 

Sugar 4.83 

Whey  protein 0 .  85 

Salts 0.64 

Water 93. 36 

It  will  be  seen  from  this  that  the  percentage  of  salts  is  practicallj^  un- 
changed as  compared  with  milk,  and  that  of  sugar  shghtly  increased. 
Certain  later  analyses  differ  from  these.  Thus  White  and  Ladd-  found 
an  average  of  1.02  per  cent,  of  protein  and  the  Department  of  Agriculture 
of  the  United  States^  one  of  1.00  per  cent. 

Whey=cream  Mixtures. — Whey  was  for  many  years  a  very  favorite 
food  for  cases  of  weak  digestion,  either  given  for  a  brief  period  alone 
except  for  the  addition  of  cane-sugar,  or  combined  with  small  amounts 
of  cream.  Falling  for  a  while  into  disuse,  its  employment  was  revived 
at  the  time  the  fear  of  the  injurious  effects  of  a  high  casein-percentage 
became  prominent;  the  purpose  being  to  replace  the  casein  by  lactal- 
bumin. In  recent  years,  with  increasing  confidence  in  the  digestibiUty 
of  casein,  the  use  of  whey  has  been  neglected  and  even  condemned,  on 
the  ground  that  the  whey-protein  was  injurious  in  many  cases  of  digestive 
disturbance.  This  neglect  has  been  harmful,  for  although  the  need  for 
whey-combinations  is  comparatively  infrequent,  yet  there  are  numerous 
instances  especially  in  early  infancy  when  they  are  of  undoubted  benefit. 
In  fact,  the  whey  is  the  element  which  contains  the  bulk  of  the  necessary 
amino-acids,  the  casein  being  very  deficient  in  these.  (See  p.  131.)  Re- 
garding the  harmfulness  it  is  doubtful  whether,  in  any  case  of  injury 
by  whey,  this  is  not  to  be  attributed  to  the  sugar  or  the  salts  rather 
than  to  the  lactalbumin. 

The  production  of  whey-cream  mixtures  in  which  the  fat  shall  be 

'  Chemie  der  menschliclie  Nahrungs-u.  Cienussmittel,  1903,  I,  389. 
^Phila.  Med.  Jour..  1901,  Feb.,  21S. 
'  BuUetiu  Xo.  28.     Kef.  White  and  Ladd,  loc.  cit. 
10 


146  THE  DISEASES  OF  CHILDREN 

sufficiently  abundant  and  the  casein  in  very  small  amount  can  be  accom- 
plished only  with  the  employment  of  the  richer  creams.  This  is  because 
with  the  weaker  creams  and  top-milks  of  from  8  to  16  per  cent,  strength, 
so  much  needs  to  be  used  to  obtain  sufficient  fat  that  a  very  considerable 
percentage  of  casein  is  necessarily  added  also.  The  whey-cream  mixtures 
are  consequently  much  better  prepared  by  laboratory-modification 
when  possible.  Using,  however,  the  top  2  oz.  of  the  quart,  contain- 
ing 24  per  cent,  of  fat,  successful  home-modifications  can  be  made.  Since 
the  desire  usually  is  to  have  present  as  much  lactalbumin  as  possible  in 
the  food  and  as  little  casein,  and  since  the  fat-percentage  of  the  whey 
is  so  low  and  so  little  cream  is  employed,  we  shall  make  no  great  error 
in  considering  the  fat  as  derived  entirely  from  the  cream  and  the  pro- 
tein and  sugar  from  the  whey.  Suppose,  for  instance,  that  3  per  cent,  of  fat 
is  desired  in  a  20  oz.  mixture,  we  can  construct  a  food  by  using  the  basic 
equation  previously  given  (p.  140).  Substituting  the  figures  we  shall 
have: 

— x-i —  =  2.5  oz.  of  24  per  cent,  cream. 
24  ' 

The  remaining  17.5  oz.  will  be  whey.  The  total  sugar-percentage  as 
derived  from  the  whey  equals  nearly  5  per  cent.  (4.83),  and  as  much  more 
sugar  may  be  added  as  is  desired  to  bring  it  up  to  the  required  percentage. 
A  closer  calculation  of  the  whey-formula  is  hardly  necessary.  Those, 
however,  who  desire  to  take  into  account  the  amount  of  casein  present 
in  the  top-milk  and  of  fat  in  the  whey  may  follow  the  methods  elaborated 
by  Westcott.^ 

Peptonized  Milk. — For  infants  "with  feeble  digestion  the  pan- 
creatizing  of  the  milk  before  it  enters  the  alimentary  canal  was  formerly 
much  used  and  was  sometimes  of  benefit.  This  is  best  accomplished 
by  the  action  on  the  milk  of  the  trypsin  derived  from  the  pancreatic 
juice  of  the  pig,  which  partially  digests  the  casein  before  it  is  ingested  and 
prevents  the  formation  of  tough  coagula.  As  the  pancreatic  extract 
requires  the  presence  of  an  alkali  in  order  to  act,  it  is  commonly  sold  com- 
bined with  bicarbonate  of  soda,  in  the  form  of  a  powder  in  individual 
glass  tubes.  These  are  preferable  to  the  "peptogenic"  powder  on  the 
market,  as  they  permit  of  greater  range  in  varying  the  food  at  will. 
The  pancreatizing  is  accomplished  by  dissolving  the  contents  of  1  tube 
in  2  oz.  of  cool  water  and  adding  to  1  pint  of  cool  milk;  and  then  allow- 
ing the  vessel  containing  the  mixture  to  stand  in  hot  water  of  a  tempera- 
ture of  not  over  115°F.  (46°C.),  i.e.  as  warm  as  the  finger  can  bear 
without  discomfort.  It  may  remain  here  for  20  or  30  minutes,  or  a 
shorter  time  if  the  slightest  bitter  taste  is  discovered,  and  is  then  quickly 
cooled  and  kept  on  ice,  or,  better,  heated  quickly  to  boihng.  The 
temperature  of  boiling  destroys  the  trypsin  and  prevents  further  pep- 
tonization, thus  avoiding  the  development  of  the  bitter  taste.  The 
peptonizing  may  be  applied  similarly  to  the  top-milk,  or  to  the  modified 
milk-mixture  after  it  has  been  prepared  in  the  ordinary  way. 

It  is  not  best  to  continue  the  use  of  peptonized  milk  for  too  long  a 
time,  as  it  takes  away  the  necessity,  and,  to  an  extent,  the  power  of  the 
digestive  organs  to  do  their  own  work.  Its  employment  is  serviceable 
only  when  there  is  a  disturbance  of  protein-digestion.  It  is  with  reason 
much  less  frequently  made  use  of  than  formerly;  but  is  certainly  service- 
able in  some  cases. 

1  Internat.  Clinics,  1900,  III. 


BASIC  EQUATION  TO  OBTAIN  THE  DESIRED  FAT-PERCENTAGE     147 

Buttermilk.  Lactic  Acid  Milk. — The  term  "buttermilk"  is 
properly  applied  to  the  milk  which  remains  after  the  butter-fat  has  been 
removed  by  churning.  Its  employm.ent  for  the  feeding  of  infants  with 
delicate  digestion,  for  many  years  widely  followed  in  Holland,  appears 
to  have  been  first  urged  upon  the  profession  by  Ballot  in  1865.^  Renewed 
attention  was  directed  to  it  by  the  writings  of  de  Jager,^  Salge,^  Teixeira 
de  Mattos,^  and,  later,  by  many  others.  The  composition  of  buttermilk 
varies  according  to  different  published  analyses,  and  depends  to  some  ex- 
tent upon  whether  made  from  whole  sweet  milk,  sweet  cream,  or  sour 
cream.  By  all  methods  the  fat-percentage  is  low,  that  of  the  protein 
rather  high,  and  that  of  the  sugar  more  or  less  reduced.  The  following 
table  gives  approximate  analyses. 

Table  47. — Approximate  Composition  of  Buttermilk 

Fat 0 . 5-1 . 0  per  cent. 

Siipar 0 . 3-4 . 0  per  cent. 

Protein 2 . 5-4 . 0  per  cent. 

The  average  composition  from  a  large  number  of  published  statistics  col- 
lected by  Konig^  gives  water  90.09,  fat  1.02,  sugar  4.24,  nitrogenous 
material  3.91,  and  salts  0.74.  Various  condensed  buttermilks  have  been 
put  upon  the  market.  These  frequently  fill  a  useful  place.  (See  p.  166.) 
Buttermilk  is  always  distinctly  acid  from  the  development  in  it  of 
lactic  acid  and  contains  usually  about  0.5  per  cent,  of  this.  If  the  acidity 
grows  too  great  the  buttermilk  separates  into  a  whey-like  and  a  more 
solid  portion.  The  casein  is  always  coagulated  and  is  in  the  form  of 
casein-lactate  and  it  will  no  longer  be  acted  upon  by  the  rennin.  The 
caloric  value  is  between  300  and  400  calories  per  litre  (284  and  379 
per  quart)  (see  also  p.  175),  being  little  if  any  stronger  than  skimmed  milk. 
Ordinary  commercial  buttermilk  is  hardly  fit  for  use  in  infant-feeding, 
as  it  is  liable  to  be  contaminated  by  undesirable  germs.  It  is  best  made 
carefully  at  home  in  the  following  manner:  A  quart  or  more  of  either 
whole-milk  or  skimmed-milk,  as  fresh  and  clean  as  possible,  is  pasteurized 
and  placed  in  a  clean  vessel.  After  the  addition  of  a  culture  of  lactic 
acid  bacilli  it  is  allowed  to  stand  for  18  to  24  hours  at  a  temperature  of 
about  100°F.  (37.8°C.).  The  Bulgarian  bacillus  cultures  are  the  most 
serviceable,  but  other  lactic  acid  germs  may  be  employed.  Since  there 
are  numbers  of  cultures  on  the  market,  many  of  which  have  little  value 
for  the  purpose  (Bendick),^  an  active  variety  should  be  selected.  After 
standing  as  directed  the  milk  is  then  churned  energetically  for  20  to  30 
minutes  in  a  small  glass  churn,  the  butter  removed,  and  the  buttermilk 
kept  on  ice  until  wanted.  Instead  of  churning  buttermilk  may  be  made 
by  using  skimmed-milk  and  beating  it  thoroughly  after  souring  has 
taken  place.  Prepared  in  either  way  the  living  lactic  acid  germs  are  still 
present,  and  are  serviceable  in  some  digestive  disturbances  where  it  is 
desired  to  destroy  by  their  growth  the  proteolytic  bacteria.  When  only 
the  chemical  action  of  the  buttermilk  is  desired,  boiling  will  destroy  the 
germs.  Boiling,  however,  curdles  the  casein  into  large  masses,  unless 
vigorous  stirring  is  used  to  prevent  this. 

Owing  to  the  low  caloric  value  buttermilk  by  itself  is  suitable  for 

1  Nederl.  Tidjschr.  v.  Geneesk.,  I«(j5,  II,  402.     Ref.  Teixeira  de  Mattos. 

2  Nederl.  Tidjsclir.  v.  Geneesk.,  1895,  XXXI,  G79. 
» Jahrb.  f.  Kiiidorh.,  1901,  LIV,  681. 

♦Jahrb.  f.  Kinderh.,  1902,  LV,  1. 

'Cliemic  dcr  nienschliclien  N.ilininRs-  und  GenussmitttI,  1903,  I,  386. 

•  Journ.  Amer.  Med.  Assoc,  1915,  LXIV,  809. 


148  THE  DISEASES  OF  CHILDREN 

infant-feeding  only  for  short  periods.  To  increase  its  strength  the  usual 
custom  is  to  add  wheat-flour  and  cane-sugar  to  it.  The  amounts  em- 
ployed vary,  but  the  preparation  is  made  in  the  following  manner  some- 
what after  the  proportions  recommended  by  Teixeria  de  Mattos:^  1 
level  tablespoonful  {}i  oz.)  of  wheat,  rice  or  other  flour  is  rubbed  into  a 
paste  with  6  to  8  oz.  of  a  quart  of  buttermilk,  and  41-2  level  tablespoon- 
fuls  (2}^  oz.)  of  granulated  sugar  are  added.  This  is  then  mixed  with  the 
remainder  of  the  quart  and  the  whole  boiled  for  25  minutes,  with  constant 
stirring.  If  it  is  desired  to  preserve  the  germs  alive,  the  flour  and  sugar 
are  boiled  in  the  8  oz.  of  buttermilk  in  a  double  boiler,  and  then  when  cool 
added  to  the  remaining  buttermilk.  Buttermilk  mixtures  prepared  in 
this  way  give  approximate  percentages  of  fat  1  per  cent.,  carbohydrate 
11  per  cent.,  protein  4  per  cent.,  based  on  Konig's  figures,  but  varying 
somewhat  with  the  buttermilk  employed.  The  advantages  of  the  butter- 
milk-mixture depend  upon  the  relationship  of  the  percentages.  It  is 
serviceable  in  cases  where  fat  is  not  at  all  well  tolerated  and  where  there  is 
no  intolerance  for  carbohydrate.  The  caloric  value  varies  between  560 
and  660  calories  per  quart  (592  and  697  calories  per  litre) .  It  is  also 
useful  from  the  fact  that  the  casein  has  already  been  coagulated  by  the 
acid,  and  is  in  a  very  finely  divided  state,  not  capable  of  being  acted  upon 
by  rennin. 

Lactic  acid  milk  is  a  term  which  might  conveniently  be  limited  to 
whole-milks  which  have  been  soured  as  for  buttermilk,  but  which  have 
not  had  the  butter-fat  removed  by  churning.  Koumys  and  Matzoon 
are  of  this  class.  They  are  suitable  for  older  children,  but  cannot,  of 
course,  be  used  where  a  milk-mixture  free  from  fat  is  desired. 

Casein  Milk  (Eiweiss  Milk.  Protein  Milk.  Albumin  Milk).— 
Although  not  a  translation  of  the  German  title  "  Eiweissmilch  "  applied 
by  Finkelstein  and  Meyer, ^  the  title  "Casein  milk"  would  appear  to  ex- 
press well  the  composition  of  the  food.  It  is  distinctly  a  casein  prepara- 
tion, not  one  of  all  the  proteins  of  the  milk.  Its  principal  purpose  is  to 
furnish  a  diet  with  a  fair  amount  of  fat ;  a  low  percentage  of  sugar,  espe- 
cially lactose;  a  reduced  percentage  of  salts  and  of  lactalbumin,  and  a 
large  amount  of  casein.  The  percentage-composition^  averages  approxi- 
mately the  figures  given  in  the  following  table: 

Table  48. — Composition  op  Casein  Milk 

Fat ,  ., 2.5  per  cent. 

Lactose 1.5  per  cent. 

Protein 3.0  per  cent. 

Salts 0.5  per  cent. 

The  amount  of  the  fat  is  somewhat  variable.  The  caloric  value  is  about 
450  per  litre  (426  per  quart)  .  A  little  saccharin  may  be  used  for  sweet- 
ening if  necessary.  The  formula  is  based  on  the  belief  that  the  sugar 
and  the  salts  of  the  food  are  the  most  dangerous  elements  in  many  dis- 
eased conditions.  By  diminishing  the  amount  of  these  the  fat  is  rendered 
more  easily  digestible.  Later,  after  the  digestion  of  the  infant  has 
improved,  the  percentage  of  sugar  is  raised  by  the  addition  of  a  dextrin- 
maltose  combination. 

The  preparation  of  casein  milk  is  rather  difficult  and  requires  close 
attention  to  details :     One  quart  of  whole-milk  is  heated  to  about  100°F. 

1  Loc.  cit. 

2BerL  klin.  Woch.,  1910,  XLVII,  1165;  Jahrb.  f.  Kinderh.,  1910,  LXXI,  525; 
Miinch.  med.  Woch.,  1911,  LVIII,  340. 

3  Finkelstein  and  Meyer  in  Feer's  Lchrb.  d.  Kinderheilk.,  1914,  252. 


BASIC  EQUATION  TO  OBTAIN  THE  DESIRED  FAT-PERCENTAGE     149 

(37,8°C.),  '}y'2  oz.  of  liquid  rennet  or  essence  of  pepsin  added,  and  the  milk 
then  allowed  to  stand  at  this  temperature  in  a  water-bath  for  half  an 
hour,  by  which  time  it  will  have  been  curdled.  The  mass  is  then  put 
upon  a  fine  cloth  and  the  whey  strained  off  without  pressing,  about  an 
hour  being  allowed  for  this.  The  curd  is  then  rubbed  through  a  very 
fine  wire  sieve,  using  the  bowl  of  a  spoon  to  do  the  rubbing,  and  a  pint  of 
water  being  used  in  the  process;  and  this  sieving  repeated  4  or  5  times, 
using  the  same  water  and  later  adding  if  necessary  enough  to  preserve 
the  original  volume.  To  the  pint  thus  obtained  1  pint  of  buttermilk 
is  added.  The  whole  is  then  steriUzed  by  boiling  vigorously  and  constantly 
stirring  during  the  process  in  order  to  prevent  clumping. 

Owing  to  the  difficulty  in  preparation,  or  as  a  result  of  efforts  made  at 
improvement,  many  substitutes  have  been  recommended  and  some  of 
them  produced  commercially  and  put  upon  the  market  (see  p.  168);  but 
a  very  similar  preparation  may  be  easily  made  at  home  by  the  method 
proposed  by  Hoobler.^  This  consists  in  mixing  10  grams  (154  grains) 
(about  1}^  level  tablespoonfuls)  of  powdered  casein  (casein-flour)  with. 
1  pint  of  previously  boiled  fat-free  buttermilk  and  1  pint  of  warm  water. 
This  gives  a  percentage  composition  of  approximately  fat  0.25  per  cent., 
carbohydrate  2  per  cent.,  protein  2.8  per  cent.  The  formula  can  be 
varied  in  different  ways  according  to  the  needs  of  the  infant.  The  fol- 
lowing formulae  serve  as  examples  of  those  employed  in  the  Children's 
Hospital  of  Philadelphia.  In  some  of  them  a  portion  of  the  milk  used  is 
fat-free  buttermilk  and  a  part  lactic  acid  milk.  (See  p.  148.)  Larosan 
(p.  168)  may  be  employed  instead  of  casein-flour  if  desired,  and  the 
mixture  resulting  is  finer  and  can  be  boiled  without  thickening. 

Table  49. — Composition  op  Various  Casein-milk  Formul.e 


Buttermilk, 
ounces 


Lactic  acid 
milk,  ounces 


Casein-flour 


Dextrin-maltose 


j    Water, 
ounces 


(1)  10 

(2)  5 
(3) 

(4) 


0 

5 

10 

1.5 


6  grams  (about  1  scant 

level  tablespoonful) 
6  grams  (about  1  scant 

level  tablespoonful) 
6  grams  (about  1  scant 

level  talDlespoonful) 
6  grams  (about  1  scant 

level  tablespoonful) 


18  grams  (about  3  scant        10 

level  tablespoonfuls) 
18  grams  (about  3  scant         10 

level  tablespoonfuls) 
18  grams  (about  3  scant         10 

level  tablespoonfuls) 
18  grams  (about  3  scant  5 

level  tablespoonfuls) 


These  give  the  following  approximate  calculated  percentages  and 
caloric  value: 


Fat 


Carbohydratn 


Calories  per  ounce 


(1) 

0.15 

(2) 

1.10 

(3) 

2.00 

(4) 

3.00 

5.25 
5.25 
5.25 

().in 


2.75 
2.75 

2.75 
3 .  (iO 


10.4 
12.7 
15.0 
20.0 


These  calculations  are  based  nipon  the  same  approximate  percentage- 
strengths  employed  in  using  ordinary  home-modifications  from  top-milk 
(p.  139),  and  arc  open  to  the  .same  criticism  of  lack  of  absohilc  accuracy. 
The  variation  is,  however,  insignificant. 

'  Arch,  of  Pcd.,  1914,  XXXI,  174. 


CHAPTER  V 

FOODS  OTHER  THAN  MILK 
PROTEIN-FOODS 

It  happens  constantly  that  some  animal  substance  other  than  milk  is 
needed  as  a  temporary  substitute  during  illness  in  the  1st  year;  or  as  a 
more  permanent  article  of  diet  after  this  period.  The  following  may 
be  mentioned: 

Albumen=water. — ^This  consists  of  the  white  of  one  hen's  egg, 
averaging  from  55  to  60  grams  (Pfund)^  (1.9  to  2  fl.oz.)  stirred  in  enough 
cool  water  to  make  8  oz.,  and  strained  if  necessary.  It  is  an  ex- 
cellent temporary  substitute  for  milk  in  acute  cases  of  failure  of 
digestion,  but  a  very  weak  one.  It  is  also  at  times  a  valuable  addition  to 
cream-and-water  mixtures,  or  cream-and-whey  mixtures,  when  it  is 
desired  to  increase  the  protein  of  the  food  by  the  use  of  some  substance 
other  than  casein.  The  possibihty  of  it  being  chrectly  absorbed  as  a 
foreign  albumin  when  intestinal  disturbance  is  present  is  not  to  be  for- 
gotten. A  sensitization  to  egg  might  be  produced  in  this  way.  Accord- 
ing to  Hammarsten"^  white  of  egg  contains  10  to  13  per  cent,  of  protein, 
a  trace  of  fat,  0.7  per  cent,  of  salts,  and  85  to  88  per  cent,  of  water.  When 
mixed  with  enough  water  to  make  8  oz.  a  protein-percentage  of  about 
1.3  is  obtained.  A  certain  proportion  of  the  egg-white,  however,  appears 
in  the  water  in  the  form  of  shreddy  material,  and  requires  to  be  removed 
by  straining.  The  actual  protein-percentage  may  thus  be  reduced  con- 
siderably. Albumen-water  may  be  given  cool  or  slightly  warm,  with  or 
without  sugar  or  with  a  pinch  of  salt,  and  from  a  glass  or  bottle  according 
to  the  taste  and  fancy  of  the  infant.  It  may  be  flavored  with  a  few  drops 
of  lemon  or  orange  juice  or  with  whiskey.  Accorchng  to  Stutzer^  1 
lb.  of  lean  beef  equals  15  eggs  in  proteid  constituent. 

Fresh  Beef=juice. — -This  may  best  be  prepared  in  either  of  two 
methods: 

1.  Season  with  salt  and  very  slfghtly  broil  a  piece  of  steak  free  from 
fat,  then  cut  it  into  small  pieces  and  express  the  juice  with  a  meat  press 
(Fig.  25).  A  lemon  squeezer  may  be  used  instead,  but  this  method  is 
more  wasteful.  A  pound  of  beef  will  make  about  2  or  3  fl.oz.  of  juice. 
The  juice  must  be  kept  on  ice  until  needed.  It  may  then  be  warmed 
slightly  or  given  cold  with  a  spoon.  Some  infants  prefer  it  with  the  addi- 
tion of  sugar. 

2.  A  pound  of  minced  steak  is  put  into  6  or  8  oz.  of  water  and 
salted  slightly.  This  is  allowed  to  stand  on  ice  over  night.  It  is  then 
squeezed  out  well  with  the  meat  press  or  is  strained  through  mushn 
by  twisting  it  tightly.  Juice  thus  obtained  is  somewhat  thinner  than  by 
the  first  method,  but  is  decidedly  larger  in  quantity. 

The  protein  of  beef-juice  varies  in  amount,  depending  upon  the  method 
emplo3^ed  in  obtaining  it.     According  to  the  statistics  given  by  Hutchi- 

1  Zeitsch.  f*  Hyg.,  1900,  XXXV,  444. 

2  Phys.  Chemie,  1904,  43.5. 

3  Centr.  f.  allg.  Gesundheitspflege,  1882,  I,  179. 

150 


ANIMAL  FOODS  151 

son^  it  varies  from  2  to  7  per  cent.  Its  fat-percentage  is  low.  Beef- 
juice  is  of  value  as  a  condensed,  stimulating  food  for  infants  who  have 
difficulty  in  digesting  the  protein  of  milk,  but  its  caloric  value  is  low  and 
it  is  not  sufficient  for  an  exclusive  diet  in  the  quantity  which  the  diges- 
tion will  safely  tolerate.  Its  administration  may  be  alternated  with 
albumen-water  or  cereal  decoctions  in  cases  where  it  is  desired  to  avoid 
milk  for  a  time.  The  daily  amount  should  be  1  to  2  teaspoonfuls  at 
first  and  gradually  increased  to  3  or  4  oz.  Beef-juice  is  also  useful 
in  cases  of  anemia  or  deficient  nutrition  as  an  adjuvant  to  the  milk- 
diet,  and  may  then  be  added  in  quantities  of  2  or  3  teaspoonfuls  to  each 
bottle,  or,  preferably,  given  separately  in  1  or  2  portions  in  the  twenty- 
four  hours  between  the  regular  feechngs.  In  the 
2d  year  of  life  beef-juice  may  well  constitute  a 
part  of  the  daily  food  for  healthy  children. 

Minced  Rare  Beef  .—A  thick  piece  of  under- 
done steak,  as  free  from  fat  and  tendon  as  possi- 
ble, is  scraped,  grated,  or  minced  very  fine; 
pounded  in  a  mortar  until  it  is  reduced  to  a 
pulp,  and  seasoned  with  salt.  For  infants  it  may 
now  be  rubbed  up  mth  a  Httle  water  until  it  is  of 
the  consistency  of  thick  cream,  and  fed  from  a 
spoon,  giving  3  or  4  teaspoonfuls  in  the  course  of 
the  day. 

Scraped  beef  is  a  very  concentrated  form  of 
nitrogenous  food,  sometimes  useful  even  in  sub- 
jects less  (than  1  year  of  age.     In  the  2d  year  1 
or  2  tablespoonfuls  of  the  scraped  meat  without      Fig.  25.— Meat  Press. 
water  may  be  given  daily  when  casein  cannot  be 

digested.  I  have  more  than  once  seen  tape-worm  develop  from  the  use 
of  raw  beef  given  in  this  way,  but  the  danger  may  be  avoided  entirely 
by  the  sHght  broihng  referred  to. 

Meat  Broths. — ^Foods  of  this  class  are  of  practically  no  value  as 
actual  nourishment,  if  of  the  class  of  "  clear  broth."  They  are  sometimes 
of  benefit  during  the  1st  year  as  a  temporary  substitute  for  milk-mixtures, 
and  in  the  2d  year  may  be  one  of  the  ordinary  articles  of  diet.  The 
principles  and  method  of  preparation  are  the  same  for  all,  and  the  follow- 
ing description  for  making  beef-broth  appHes  to  the  others:  1  pound 
of  lean  meat  is  cut  into  small  pieces,  and  these,  together  with  portions  of 
the  cracked  bones  put  into  1  pt.  of  cold  water.  This  is  heated  very 
slowly,  allowing  it  to  simmer  for  3  or  4  hours;  replacing  the  water  as  it 
evaporates;  and  then  strained,  cooled  and  the  fat  removed.  The  refrain- 
ing from  straining,  thus  leaving  in  the  finely  divided  muscle-fibre,  increases 
the  nutritive  value  very  decidedly.  The  addition  of  a  cereal  flour  also 
adds  to  the  value  as  a  food,  and  makes  it  a  very  serviceable  article  of 
diet  in  the  2d  year,  or  for  temporary  use  to  replace  milk  in  digestive 
disturbances  in  the  1st  year. 

Beef=tea.— This  may  be  prepared  as  follows:  (1)  Scrape  or  cut 
fine  1  pound  of  lean  meat  and  place  in  1  pint  of  cold  water  in  ajar.  Let 
it  stand  in  the  cold  for  1  hour,  stirring  occasionally.  Then  heat  the  jar  in 
a  saucepan  of  water  at  not  over  1G7°F.  (75°C.)  for  another  hour,  stirring 
occasionally.  It  should  then  be  raised  to  the  boiling  point  for  a  moment, 
strained,  cooled  and  the  fat  removed.  Warm  sUghtly  and  season  before 
giving  it.  In  place  of  straining,  the  liquid  may  be  simply  poured  off. 
1  Food  and  Dietetics,  1901,  97. 


152  THE  DISEASES  OF  CHILDREN 

To  this  should  be  added  the  additional  liquid  obtained  by  firmly  pressing 
the  pieces  of  meat  which  remain.  (2)  Another  more  rapid  method  is  the 
following:  Place  the  pound  of  meat  in  3^^  pint  of  boiling  water.  Keep 
this  gently  warm  for  10  minutes;  strain;  cool  rapidly  and  remove  the  fat. 

Beef-tea  is  distinguished  from  beef-broth  particularly  by  the  consider- 
able amount  of  gelatin  contained  in  the  latter.  This  is  derived  from  the 
prolonged  boiling  of  the  bones  and  of  the  connective  tissue.  Beef-tea 
has  little  nutritive  value,  and  practically  none  at  all  if  sufficient  heat  has 
been  used  to  coagulate  the  protein,  and  if  this  has  been  removed  by  strain- 
ing.    If  the  fluid  is  not  strained,  the  food-value  is  decidedly  increased. 

Veal  Tea. — This  preparation,  formerly  much  in  vogue,  is  very 
similar  in  its  composition  and  in  its  strength  to  beef-tea.  It  may  be 
made  as  follows:  Cut  fine  1  pound  of  veal  as  free  from  fat  as  possible, 
put  into  1^4.  pints  of  cool  water;  let  stand  in  the  cold  for  1  hour;  then 
keep  warm  without  boihng  for  3  or  4  hours;  strain;  let  cool  and  skim  off 
the  fat. 

Gelatin. — About  20  grains  of  gelatin  are  soaked  for  a  short  time  in 
cold  water,  and  then  dissolved  with  stirring  in  3^^  pint  of  boihng  water. 
Gelatin  as  an  element  of  milk-mixtures  was  very  popular  in  former  years. 
Its  mechanical  action  in  the  food  is  very  similar  to  that  of  barley-water. 
Chemically  it  possesses  but  little  food-value. 

Soy  Bean  Flour. — This  substance  may  be  properly  classed  among 
protein-foods  serviceable  for  temporary  use  when,  for  any  reason,  the 
protein  of  milk  is  not  desired.  According  to  Ruhrah^  it  contains  approxi- 
mately 35  to  40  per  cent,  of  protein,  4  per  cent,  of  fibre,  9  per  cent,  of 
starch,  sugar  and  dextrin,  and  18  to  19  per  cent,  of  fat.  Made  into  a 
flour  the  protein  is  over  44  per  cent. 

AMYLACEOUS  FOODS 

The  employment  of  starchy  foods  in  the  1st  year  has  already  repeat- 
edly been  referred  to.  (See  pp.  124,  130,  141,  144,  etc.).  Although  the 
power  of  digesting  starch  is  present  in  early  infancy,  there  is  no  need  for  the 
administration  of  it  to  the  healthy  normal  artificially  fed  infant  during 
the  early  part  of  the  1st  year.  The  addition  of  starch  to  the  diet  in  the 
latter  part  of  the  year  is  usually  advantageous  in  order  to  accustom 
the  child  to  this  food.  In  the  case  of  illness,  however,  weak  or  stronger 
amylaceous  additions  or  substitutions  are  often  of  the  greatest  value, 
and  this  is  particularly  true  when  there  is  difficulty  in  the  digestion 
of  sugar.  Starch  is  also  used  to  prevent  the  casein  from  forming  tough 
coagula,  approximately  0.7  per  cent,  of  starch  in  the  milk-mixture  being 
the  best  amount  to  accomphsh  this  (White). ^  For  infants  in  the  1st  year 
the  amylaceous  food  is  generally  either  a  cereal-flour  or  arrowroot,  and  is 
usually  given  in  the  form  of  a  decoction  of  various  strengths.  After 
this  period  cereal-gruels  become  a  recognized  part  of  the  diet. 

The  Weight  of  Various  Carbohydrate  Substances.  (See  also  p. 
135). — In  the  making  of  amylaceous  decoctions  in  the  home,  measuring 
by  bulk  is  usually  the  only  method  which  can  be  employed;  but  for  better 
knowledge  it  is  necessary  to  know  the  weight  also,  in  order  to  estimate 
the  percentages  obtained.  Tablespoons  are  the  measure  oftenest 
used,  but  as  these  vary  so  much  in  size,  it  is  better  to  employ  the  Chapin 
dipper  or  other  ounce  measure.     I  have  made  a  series  of  weighings, 

1  Arch,  of  Ped.,  1909,  XXVI,  496;  Amer.  Jour.  Med.  Sci.,  1915,  CL,  502. 

2  Journ.  of  Bost.  Soc.  of  Med.  Imp.,  1900,  V,  125 


AMYLACEOUS  FOODS  153 

with  the  results  shown  in  the  table  which  follows.  They  correspond 
fairly  closely  with  those  determined  by  Chapin^  and  with  those  obtained 
for  me  by  Dr.  A.  Graeme  Mitchell.  The  figures  can  be  only  average  ones, 
especially  as  regards  the  weight  of  the  tablespoonful.  Barley  and  oat 
flours  are  sHghtly  hghter,  and  rice  and  wheat  flours  shghtly  heavier  than 
the  figures  given.  In  measuring,  the  tablespoon  or  the  dipper  should  be 
filled  from  a  smaller  spoon,  tapped  sharply  2  or  3  times,  and  the  excess 
scraped  off  with  a  case-knife.  Too  much  tapping  settles  the  contents 
too  greatly.     Casein-flour  is  included  as  a  convenience. 

Table  50. — Approximate  Weights  of  Grains,  Flours  and  Sugars 
(Measured  by  Tablespoon  and  by  Fl.  oz.  Dipper) 
1  Level  tablespoonful  of  barley  or  other  flour  weighs  about  J^  oz.  Av. 
1  Level  dipper  of  barley  or  other  flour  weighs  about  }i  oz.  Av. 
1  Level  tablespoonful  of  Bermuda  arrowroot  weighs  about  %  oz.  Av. 
1  Level  dipper  of  Bermuda  arrowroot  weighs  about  %  oz.  Av. 
1  Level  tablespoonful  of  pearl  barley  weighs  about  3^  oz.  Av. 
1  Level  dipper  of  pearl  barley  weighs  about  %  oz.  Av. 
1  Level  tablespoonful  of  rice  weighs  about  ^^  oz.  Av. 
1  Level  dipper  of  rice  weighs  about  j^i  oz.  Av. 
1  Level  tablespoonful  of  rolled  oats  weighs  about  }^  oz.  Av. 
1  Level  dipper  of  rolled  oats  weighs  about  3^  oz.  Av. 
1  Level  tablespoonful  of  lactose  weighs  about  3>^  oz.  Av. 
1  Level  dipper  of  lactose  weighs  about  %  oz.  Av. 
1  Level  tablespoonful  of  dextrin-maltose  weighs  about  K  oz.  Av. 
1  Level  dipper  of  dextrin-maltose  weighs  about  J^  oz.  Av. 
1  Level  tablespoonful  of  saccharose  weighs  about  }i  oz.  Av. 
1  Level  dipper  of  saccharose  weighs  about  1  oz.  Av. 
1  Level  tablespoonful  of  casein-flour  weighs  about  3^  oz.  Av. 
1  Level  dipper  full  of  casein-flour  weighs  about  3^  oz.  Av. 

Strength  of  Cereal  Gruels.- — It  is  of  distinct  advantage  to  know 
with  approximate  accuracy  the  actual  amount  of  the  ingredients  con- 
tained in  the  various  cereal  gruels  employed.  The  matter  has  been 
studied,  by  Chapin-  and  others.  The  following  Table  gives  the  approxi- 
mate percentage  formula  of  some  of  these  gruels.^     (Table  51.) 

The  fat  and  mineral  matter  are  present  in  such  small  amounts  that 
they  may  be  ignored  for  practical  purposes,  and  it  is  hardly  necessary  to 
take  the  protein  into  consideration.  Simple  gruels  cannot  be  made 
stronger  than  about  2  oz.  of  the  flour  to  the  quart.  If  more  concentrated 
preparations  are  desired  they  must  be  dextrinized  (p.  155). 

Various  Starchy  Decoctions.  Barley-water.  —  Barley-water  is 
made  either  from  pearl  barley  or  from  barley-flour.  With  the  former  2 
level  tablespoonfuls  of  pearl  barley,  previously  well  washed  for  some  time 
in  cold  water,  are  placed  in  1  quart  of  water,  let  simmer  slowly  until  the 
liquid  is  reduced  to  1  pint  in  volume,  and  then  strained.  This  should 
be  quite  fluid  in  consistency  when  slightly  warmed.  In  place  of  the 
whole  grain  1  level  tablespoonful  of  barley-flour  may  be  boiled  slowly  in 
1  pint  of  water  for  15  minutes,  with  stirring,  and  then  strained,  replacing 
the  water  which  has  boiled  away.  This  has  the  advantage  that  it  can 
be  made  much  more  rapidly  and  conveniently.  As  with  all  amylaceous 
decoctions  it  should  be  prepared  fresh  daily  and  kept  on  ice,  as  it  sours 
readily. 

Barley-water  is  a  very  commonly  used  temporary  substitute  for  milk 

1  Med.  Rec,  1905,  LXVII,  246. 
"^Lnc.  cit. 

'  The  analyses  are  those  published  by  the  Cereo  Company  of  Tappan,  New  York, 
and  based  on  gruels  made  of  flours  furnislicfl  Uy  them. 


154 


THE  DISEASES  OF  CHILDREN 


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AMYLACEOUS  FOODS  155 

in  cases  of  acute  indigestion  where  abstinence  from  food  is  the  best  cure. 
Its  nutritive  power  being  extremely  slight,  it  is  given  in  this  case  not  so 
much  for  nourishment  as  for  the  allaying  of  hunger  at  the  time.  When 
used  as  a  diluent  of  milk-mixtures  it  is  supposed  to  have  a  somewhat 
constipating  action,  but  this  is  by  no  means  alw^ays  the  case. 

Barley-jelly  is  the  term  apphed  to  a  thicker  barlej^-decoction  which 
jellies  firmly  when  cool.  It  is  made  by  using  4  level  tablespoonfuls  of 
pearl  barley  to  the  quart  of  water,  or  3  of  barley-flour  to  the  pint.  A 
double  boiler  may  be  used  to  advantage  to  prevent  burning. 

Oatmeal -water. — This  may  be  made  in  the  following  manner: 
Put  2  level  tablespoonfuls  of  oatmeal  into  1  pint  of  water.  Let  simmer  for 
2  hours  or  more,  replacing  the  water  as  it  evaporates;  strain.  An  oaimeal- 
jelly  may  be  made  in  a  way  similar  to  that  employed  for  making  barley- 
jelly,  using  4  level  tablespoonfuls  to  the  pint  of  water,  and  cooking  as 
for  oatmeal-water,  although  in  a  double  boiler.  Oatmeal-w^ater  or 
oatmeal-jelly  is  used  with  milk  as  are  the  analogous  preparations  of 
barley.  It  is,  however,  distinctly  laxative  to  many  children,  and  is 
often  a  useful  addition  where  there  is  constipation.  In  many  cases 
oatmeal  disagrees  decidedly.  If  amylaceous  food  is  to  be  added  during 
the  1st  year,  some  other  than  oatmeal  should  generally  be  first  tried. 

Rice-water. — The  method  employed  is  the  adding  of  2  level  table- 
spoonfuls of  washed  rice  to  1  quart  of  water,  boiling  to  1  pint  and  strain- 
ing, and  then  mixing  with  the  food  in  the  same  proportions  as  with 
barley-water.  It  is  supposed  to  have  a  constipating  effect,  and  is  often 
used  when  there  is  a  tendency  to  diarrhea.  Its  actual  value  for  such  a 
purpose  is  doubtful.  In  place  of  the  rice-grain,  rice-flour  may  be  em- 
ployed, using  1  level  tablespoonful  to  1  pint  of  water,  boiling  for  15  min- 
utes and  straining.  Rice  is  richer  in  carbohydrate  and  poorer  in  protein 
than  the  other  cereals  mentioned. 

Arrowroot. — This  is  a  serviceable  food  when  a  starchy  addition  is 
required.  It  is  almost  a  pure  starch,  containing  almost  no  protein. 
It  may  be  given  in  the  form  of  arrowroot-water,  which  is  made  by  adding 
1}^^  level  tablespoonfuls  of  Bermuda  arrowroot  to  1  pint  of  water  and 
boiling  for  5  or  10  minutes.  Arrowroot-jelly  is  made  by  using  4  level 
tablespoonfuls  of  arrowroot  to  the  pint  of  water,  and  boiling  for  a  few 
minutes  in  a  double  boiler. 

Bean-flour. — This  has  been  employed  in  the  form  of  a  gruel  when, 
with  the  addition  of  carbohydrate,  it  is  desired  to  increase  the  protein- 
content  of  the  food  decidedly  by  the  use  of  a  vegetable  product  rich 
in  this  substance.  The  Soy  bean  (p.  152),  recommended  for  infant-feed- 
ing especially  by  Ruhrah,^  contains  so  little  starch  that  it  cannot  be 
properly  classified  among  amylaceous  foods. 

Dextrinized  (Malted)  Starch.— The  addition  of  malt-extract  to 
boiled  starch  rapidly  dissolves  it,  transforming  it  into  dextrin  and  maltose 
and  intermediate  substances.  Starch,  as  such,  ceases  to  be  present  if 
the  dextrinizing  is  complete.  Treated  in  this  way  it  becomes  very  absorb- 
able and,  added  to  the  milk-mixture,  often  aids  greatly  in  nourishing 
infants  with  feeble  powers  of  digestion  or  assimilation  of  fat  or  of  lactose. 
The  various  commercial  dextrin-maltose  preparations  on  the  market  are 
of  this  class.  (See  pp.  129,  163.)  As  made  at  home,  1  lluidracliiu  of  a 
powerful  diastatic  malt  extract,  such  as  Cereo,  will  transform  the  starch 
of  10  oz.  of  a  10  per  cent,  amylaceous  decoction.  According  to  inves- 
tigations made  for  me  by  Dr.  A.  Graeme  Mitchell  at  the  Children's 
>  Arch,  of  Perl.,  1«)0«),  XXVI,  490;  Amor.  Jour.  Med.  Sci.,  1915,  CL,  502. 


156  THE  DISEASES  OF  CHILDREN 

Hospital  of  Philadelphia,  }i  of  the  starch  of  such  a  decoction  of  arrow- 
root was  converted  into  a  copper-reducing  substance  in  15  minutes  at  a 
temperature  of  140°F.  (60°C.),  and  a  longer  time  or  a  larger  amount  of 
the  extract  would  convert  all  or  the  greater  portion  of  it.  7  grains  of 
potassium  carbonate  should  then  be  added  to  each  ounce  of  the  mixture. 
The  dextrinized  preparation  may  replace  in  part  the  water  of  the  milk- 
mixture.  The  malt-extract  should  be  added  to  the  cereal-jelly  while 
the  latter  is  still  warm,  about  120°  to  150°F.  (48.9  to  65.5°C.)  and  main- 
tained at  this  temperature,  with  occasional  stirring,  for  20  to  30  minutes. 
Dextrinized  starch  produced  in  this  way,  as  also  with  the  commer- 
cial dextrin-maltose  preparations,  has  an  action  different  from  that  of 
the  pure  sugars.  These  latter  become  very  promptly  assimilable,  while  the 
dextrin  of  the  dextrin-maltose  possesses  a  colloidal  action  resembling  that 
of  starch,  and  is  also  slower  in  being  transformed  and  consequently  in 
being  absorbed.  The  relative  amount  of  dextrin  and  maltose  present 
depends  upon  the  temperature  employed.  (See  p.  129.)  If  this  is  below 
55°C.  (131°F.),  there  is  more  maltose  resulting;  if  above  63°C.  (145.4°F.), 
more  dextrin.  If  above  75°C.  (167°F.)  the  diastatic  ferment  is  destroyed 
(Morse  and  Talbot).^  The  strength  of  milk-mixtures  is  very  consider-, 
ably  increased  in  the  percentage  of  carbohydrate  when  dextrinized  gruels 
are  employed.  The  degree  of  increase  can  be  approximately  determined 
by  estimating  the  amount  of  amylaceous  flour  employed  (see  pp.  153, 154), 
ignoring  the  content  of  the  malt-extract  if  but  little  of  this  has  been 
used. 

Malt-soup. — A  sharp  distinction  is  to  be  drawn  between  the  food  in 
which  malt-soup  takes  a  part,  and  that  to  which  simple  dextrin-maltose 
preparations  or  completely  dextrinized  gruel  has  been  added.  With 
the  latter  no  starch  is  present,  while  with  malt-soup  there  is  a  very 
decided  proportion  of  this  intentionally  remaining  unconverted.  The 
dextrinized  preparation  made  at  home  as  just  described  is  a  malt-soup 
if  the  process  is  not  continued  to  the  complete  converting  of  the  starch. 
The  preparation  was  first  made  and  urged  by  Liebig,-  but  was  later  modi- 
fied by  Keller,^  and  came  rapidly  into  prominence  as  a  serviceable  form 
of  nourishment  for  a  certain  class  of  sick  infants.  Its  value  rests  on 
the  fact  that  a  large  percentage  of  unconverted  starch,  together  with  malt- 
ose and  dextrin,  is  present  in  the  food.  The  method  of  preparation  as 
commonly  advised  is  as  follows: 

1.  1^  oz.  Av.  (63^  level  tablespoonfuls)  of  wheat-flour  are  mixed 
with  11  fl.oz.  of  cold  cow's  milk  and  rubbed  through  a  sieve. 

2.  23^^  fl.  oz.  of  malt-soup  extract  are  added  to  22  fl.oz.  of  warm  water. 
The  two  are  then  added  one  to  the  other  and  the  whole  heated  slowly 

to  boiling,  with  constant  stirring,  and  enough  water  finally  added  to 
replace  that  which  has  evaporated.  The  malt-soup-extract  should  con- 
tain 7  grains  of  carbonate  of  potash  to  the  fluidounce,  the  object  of  this 
being  to  alkalinize  it  and  thus  to  remove  its  diastatic  action,  as  also  to 
prevent  the  development  of  any  acidosis  in  the  infant.  The  caloric 
value  of  this  mixture  is  about  625  calories  per  quart  (660  per  litre). 
Some  of  the  malt-extracts  upon  the  market  already  have  the  alkali  added;* 
others  must  have  this  added  before  using.'^     The  formula  given  produces 

^  Diseases  of  Nutrition  and  Infant  Feeding,  1915,  195. 

^  Suppe  fiir  Sauglinso,  1865. 

^  Malzsuppe,  eine  Nahrung  fiir  magendarmkranke  Siiiiglinge,  1898. 

*  Maltine  Co.;  Loeflund;  Borcherdt. 

^  Freihofer  Co. ;  Neutral  Maltose. 


AMYLACEOUS  FOODS 


157 


percentages  of  approximately  fat  1.33,  carbohydrate  11.4,  protein  1.58. 
It  is  not,  however,  necessary  to  use  these  amounts.  Experiments  con- 
ducted for  me  at  the  Children's  Hospital  of  Philadelphia  by  Dr.  A.  Graeme 
Mitchell  evolved  the  following  formulae  which  will  be  found  convenient. 


Table  52. — Percentage-stbengths  Various 

(a) 
Wheat-flour,  J^^  oz.  (2  level  tablespoonfuls) 
Skimmed  milk,  10  oz. 
Malt-soup-extract,  loz. 
Water  to  make  20  oz. 

(b) 
Wheat-flour,  H  oz.  (2  level  tablespoonfuls)  1 
Whole-milk,  5  oz.  I 

Skimmed  milk,  5  oz.  [ 

Malt-soup-extract,  1  oz.  J 

Water  to  make  20  oz. 

(c) 
Wheat-flour,  3^  oz.  (2  level  tablespoonfuls)  "1 
MUk,  10  oz.  [ 

Malt-soup-extract,  1  oz.  J 

Water  to  make  20  oz. 

(d) 
Wheat-flour,  1  oz.  (4  level  tablespoonfuls)     1 
Milk,  10  oz.  [ 

Malt-soup-extract  1^^  oz.  J 

Water  to  make  20  oz. 

(e) 
Wheat-flour,  IJ-2  oz.  (6  level  tablespoonfuls)  ] 
Milk,  10  oz. 

Malt-soup-extract,  l^i  oz. 
Water  to  make  20  oz. 


Malt-soup  Mixtures 

Per  cent. 

Fat  =    0.35 

Carbohydrate   =     7.5 
Protein  =    2 .  24 


Fat  =1.0 

Carbohydrate  =    7.5 
Protein  =    2.24 


Fat  =2.0 

Carbohvdrate  =    7.5 
Protein"  =    2 .  24 


Fat  =2.0 

Carbohydrate  =  11.0 
Protein  =     2.6 


Fat  =2.1 

Carbohydrate  =  13.84 
Protein  =    2 .  86 


In  these  calculations  the  same  approximate  percentages  were  employed 
as  adopted  for  the  making  of  ordinary  home-modifications  from  top- 
milk.     (See  p.  139.) 

Flour -ball. — Flour-ball  was  formerly  much  employed  as  an  addition 
to  milk  when  a  cereal  was  required.  It  is  made  by  tying  a  pound  of 
flour  tightly  in  a  bag  and  boiling  for  10  hours.  When  cold  it  is  taken 
from  the  bag  and  completely  dried  with  heat.  The  outer  coating  is  then 
removed,  and  the  remaining  inner  portion  grated.  1  or  2  teaspoonfuls 
are  added  to  each  bottle.  The  advantage  claimed  for  it  was  that  the 
flour  was  partially  dextrinized  and  thus  rendered  more  soluble,  requiring 
less  cooking.  Dextrinized  cereal  flour  can,  however,  be  produced  much 
more  easily  in  the  manner  already  described. 


CHAPTER  VI 

SPECIAL  NAMED  MIXTURES  AND  PROPRIETARY  FOODS 

SPECIAL  MIXTURES  WITH  PERSONAL  NAMES 

There  have  been  recommended  a  very  large  number  of  special  mix- 
tures to  which  are  often  attached  the  names  of  the  physicians  first  de- 
scribing them.  A  few  of  these  are  mentioned  below  on  account  of  the 
frequency  with  which  the  names  are  met  with,  not  because  of  a  desire 
especially  to  advocate  them.  It  must  be  remembered  that  modern 
scientific  pediatrics  is  opposed  to  the  use  of  any  one  preparation  as  a 
routine  feeding.  Rather  must  the  mixture  be  modified  to  meet  the  needs 
of  the  case.  Some  of  the  preparations  mentioned  have  indeed  been 
manufactured  and  sold  commercially,  and  would  be  more  properly 
included  in  the  next  section. 

Meigs  Gelatin  Food. — This  was  a  formula  found  very  useful  years 
ago  by  J.  F.  Meigs  of  Philadelphia,  and  mentioned  here  because  the  title 
is  still  widely  known.  It  consisted  of  1  scruple  of  gelatin  dissolved  in 
8  055.  of  boiled  water  to  which  was  then  added  1  teaspoonful  of  arrowroot 
with  milk  and  cream  in  varying  proportions,  depending  upon  the  age 
and  digestive  power  of  the  child  (Meigs  and  Pepper).^ 

Biedert's  Cream  Mixtures  (Rahmgemenge).^ — These  consist  of 
modified  milks  constructed  by  mixing  certain  proportions  of  cream  with 
milk,  water,  and  milk-sugar,  thus  producing  a  series  of  formulse.  The 
principle  is  thoroughly  scientific  and  the  food  was  the  prototype  of  many 
milk  modifications  later  made  in  Germany,  as  well  as  of  all  percentage 
feeding  combinations.  The  chief  objection  to  the  employment  of  these 
mixtures  is  that,  according  to  the  formulae  and  the  percentages  given,  the 
altering  of  the  percentage  of  one  ingredient  without  affecting  that  of 
another  is  not  easy.  Later  a  condensed  modified  cream-mixture^  prepared 
according  to  Biedert's  formula,  was  placed  on  the  market.  It  will  be 
found  mentioned  under  Commercial  Foods  (p.  166). 

Gartner's  Mother  Mill<  (Fatty  Milk).^ — This  is  made  by  cen- 
trif  ugating  diluted  milk  and  adding  to  the  richer  portion  milk-sugar  and 
an  alkali.  The  mixture  is  then  sterilized.  The  food  is  in  reality  a  modi- 
fied milk.  It  is  supposed  to  possess  the  same  percentages  of  fat,  sugar 
and  protein  as  are  contained  in  average  human  milk.  It  is  subject  to  the 
disadvantage  of  all  such  mixtures,  that  the  relationships  of  the  ingre- 
dients to  each  other  are  fixed.  As  the  food  has  become  a  commercial 
one  its  analysis  will  be  given  later  (p.  166). 

Von  Dungern's  Renneted  Milk.^- — The  milk  is  treated  with  rennet 
and  the  coagulated  mass  finely  divided  by  shaking.  It  is  claimed  that  it 
is  rendered  more  digestible  in  this  way,  since  the  formation  of  large  curded 
masses  in  the  stomach  is  prevented.  The  rennet  used  is  contained  in 
a  preparation  with  the  trade  name  of  Pegnin. 

1  Diseases  of  Children,  1877,  p,  332. 

2  Beidert,  Der  Kinderernahrung  im  Sauglingsalter,  1900,  189. 
^  Kiinstliche  Rahmgemenge;  Ramogen. 

*  Wien.  med.  Wochenschr.,  1894,  XLIV,  1870. 
6  Miinch.  med.  Wochenschr.,  1900,  No.  48. 

158 


SPECIAL  MIXTURES  WITH  PERSONAL  NAMES  159 

Szekely's  Casein=free  Milk.'- — Skimmed  milk  is  heated  at  about 
60°C.  (140°F.)  in  closed  vessels  under  pressure  and  subjected  to  liquid 
carbonic  acid  which  largely  precipitates  the  casein.  The  whey  remain- 
ing is  mixed  with  cream  and  sugar. 

Voltmer=Lahrmann's  Pancreatized  Milk. 2— This  is  merely  a 
pancreatized  mixture  of  cream,  milk,  water  and  sugar,  with  potassium 
carbonate  in  varying  amounts,  to  which  later  phosphoric  acid  is  added. 

Backhaus'  Milk.^ — This  consists  of  fat-free  milk  treated  with 
rennet.  In  this  way  a  portion  of  the  casein  is  coagulated  and  then 
removed.  To  the  whey  remaining  milk-sugar  and  cream  are  then  added. 
More  recently  maltose  and  dextrin  are  used.  The  food  has  now  become 
a  commercial  one,  three  different  strengths  being  sold  (p.  166).  The 
preparations  are  very  similar  in  percentages  to  those  obtained  by  Biedert's 
formulae. 

Monti's  Whey  Milk.* — The  food  consists  in  varying  mixtures 
of  whey  and  whole  milk  rich  in  fat.  In  this  way  the  lactalbumin  is 
increased  in  amount  and  the  casein  relatively  diminished. 

Steffen's  Veal  Broth  and  Milk^  is  a  mixture  of  100  grams  (3.4  fl.oz.) 
each  of  veal-broth  and  milk  to  which  are  added  1  teaspoonful  of  cream 
and  3.8  grams  (0.13  fl.oz.)  of  milk-sugar. 

Hesse=Pfund's  Infant's  Food.^ — Water  and  cream  are  mixed  in 
certain  proportions  and  to  them  is  added  a  sterilized  powder,  consisting 
of  hen's  eggs  and  milk-sugar  with  a  small  amount  of  a  salt  of  iron.  The 
amounts  of  the  non-coagulable  protein,  fat,  and  sugar  are  thus  increased. 

Vigier's  Humanized  Milk.^^ — -The  method  of  preparation  consists  in 
first  dividing  a  quantity  of  milk  into  two  equal  portions.  On  the  first 
half  the  cream  was  allowed  to  rise  and  was  removed,  and  from  the  fat- 
free  remainder  whey  was  prepared.  This  and  the  cream  were  then 
added  to  the  second  half  of  the  milk.  The  resulting  mixture  was  to 
some  extent  like  that  of  some  of  Biedert's  cream  mixtures,  but  the  per- 
centages were  inferior. 

Lehndorf  and  Zak  Dialized  Milk.^ — This  preparation  was  especially 
recommended  for  cases  where  there  was  indigestion  of  sugar.  It  is  made 
by  placing  about  a  pint  of  milk  in  a  parchment  bag  and  suspending  this 
in  a  number  of  quarts  of  water,  renewing  every  hour.  The  sugar  and 
salts  pass  to  a  large  extent  through  the  parchment. 

Homogenized  Milk.  (Raudnitz).^— The  milk  is  minutely  divided 
by  atomizing  under  high  pressure.  This  renders  the  fat-globules  ex- 
ceedingly small.  The  cream  will  no  longer  rise  and  the  coagulum  with 
acid  resembles  that  of  human  milk. 

Peer's  Milk  Preparation.'"— This  is  composed  of  whole  milk  500 
grams  (16.9  fl.oz.),  cream  (20  per  cent.)  50  grams  (1.7  fi.oz.),  Soxhlet's 
Nahrzucker  10  to  50  grams  (0.35  to  1.8  oz.  Av.),  plasmon  15  grams  (0.53 
oz.  Av.),  water   600   grams    (20.29  fl.oz.).     This   gives  a   preparation 

'  Mlinch.  med.  Wochenschr.,  1905,  LV,  878. 

^  Ref.  Raudnitz,  in  Pfaundler  und  Schlossmann,  Handb.  der  Kinderli.,  lOOO,  I,  311. 

3  Berl.  klin.  Wochenschr.,  1895,  XXXII,  501 ;  589.  Herl.  Molkereiztg.,  1905,  No. 
42.     Ref.  Raudnitz,  Monatschr.  f.  Kinderh.,  1905,  IV,  583. 

*  Kinderheilkunde,  1899,  I,  158. 

» Jahrb.  f.  Kinderheilk.,  1895,  XL,  421. 

«  Archiv  fur  Kinderheilk.,  1898,  XXIV,  22();  1903,  XXXVI,  407. 

'  Soci6t6  de  therap.,  1893,  Jan.  25.  Ref.  Marfan,  Trait6  dc  rallaitement,  1903, 
439. 

«  Wien.  med.  Wochensch.,  1910,  LX,  1930 

»  Pfaundler  u.  Schlossmann,  Handl).  d.  Kinderh.,  1900,  I,  1,  310. 

»»  Jahrb.  f.  Kinderh.,  1913,  LXXVIII,  1. 


160  THE  DISEASES  OF  CHILDREN 

consisting  of  fat  2.3  per  cent.,  sugar  6.2  per  cent.,  protein  2.6  per  cent., 
salts  0.44  per  cent.  The  purpose  of  the  food  was  to  render  the  fat  better 
tolerated  by  the  removal  of  part  of  the  whey.  The  lack  of  protein 
caused  by  the  dilution  is  made  up  by  the  plasmon. 

Schloss'  Modified  Milk.^ — This  is  a  cream,  whole  milk  and  water 
mixture  to  which  Soxhlet's  Nahrzucker,  mondamin,  and  nutrose  or  plas- 
mon have  been  added. 

Friedenthal's  Milk.^ — The  principle  of  the  Friedenthal  milk  is 
based  especially  on  an  effort  to  render  the  mineral  matter  of  the  food 
similar  to  that  of  human  milk.  An  artificial  human-milk  serum  is  made 
by  dissolving  in  water  the  required  salts.  To  this  white  of  egg  and 
powdered  casein  are  added,  and  the  mixture  used  as  the  basis  for  the 
infant's  food. 

PROPRIETARY  (COMMERCIAL;  PATENTED)  FOODS 

The  so-common  and  wide-spread  employment  of  the  proprietary 
infant-foods  is  probably  one  of  the  most  pernicious  factors  of  the  time  in 
the  feeding  of  infants,  as  indeed  it  has  been  for  years.  It  is  not  because 
the  composition  of  these  foods  is  necessarily  faulty  which  renders  them 
so  harmful,  although  this  is  frequently  the  case,  but  it  is  the  manner  in 
which  they  are  freely  advertised  to  the  laity  as  "the  only  proper  substi- 
tute for  mother's  milk,"  and  freely  used  by  mothers  without  consultation 
with  physicians.  It  is  frequently  only  after  an  infant  becomes  ill, 
having  taken  a  large  variety  of  the  foods  for  weeks  or  months,  that  the 
advice  of  the  physician  is  asked  about  the  propriety  of  their  use.  In 
other  cases  physicians  themselves  are  largely  responsible  for  this  state  of 
affairs,  as  they  are  prone  to  yield  too  readily  to  the  temptation  to  pre- 
scribe the  foods  without  due  consideration.  This  saves  the  physician' 
thought,  and  is  the  worst  thing  possible  both  for  him  and  for  the  patient. 

The  proprietary  foods  are  unreliable  and  unnecessary :— unreliable, 
because  they  are  never  the  perfect  substitute  for  mother's  milk  in  spite 
of  the  claims  of  the  manufacturers ;  unnecessary  because  it  is  rare  that  they 
cannot  be  entirely  dispensed  with.  Moreover,  in  the  case  of  those  in- 
tended to  be  used  without  the  addition  of  milk,  the  element  of  freshness, 
so  important  in  infant-nourishment,  is  lacking;  while  in  the  case  of  the 
others  the  question  arises,  why  use  them  at  all  if  fresh  cow's  milk  must  also 
be  employed  in  any  event?  They  also  have  the  additional  disadvantage 
that  the  ingredients  bear  a  fixed,  unvarying  relationship  to  each  other,  and 
the  ready  changing  of  these,  which  modern  infant-feeding  considers  indis- 
pensable, is  an  impossibility.  It  is  true  that  many  infants  have  done  well 
upon  commercial  foods  after  some  milk-modifications  had  failed;  but  they 
would  almost  certainly  have  grown  as  satisfactorily  without  them  and 
with  much  less  risk.  What  they  needed  was  a  proper  milk-modification. 
There  can  be  nothing  of  advantage  in  a  proprietary  food  which  cannot  be 
equally  incorporated  in  a  home-made  modification,  and  at  much  less 
expense.  It  is  still  more  true  that  not  only  have  countless  deaths  arisen 
from  their  use,  but  that  countless  infants  have  suffered  from  rickets, 
scurvy,  and  severe  gastro-intestinal  disorders  as  a  result  of  their  em- 
ployment. Cases  do  occasionally  occur  where  the  temporary  use  of  a 
proprietary  food  may  be  a  necessity  because  nothing  else  can  be  obtained 
or  for  some  other  unusual  reason;  or  beneficial,  just  as  barley-water, 
beef-juice,   or  other  food  than  milk  is  sometimes  demanded.     These 

^Ueber  Sauglingsernahrung,  1912. 

2  Zentralbl.  f.  Physiol.,  1910,  XXIV,  687. 


PROPRIETARY  FOODS  161 

cases  are  certainly  the  exception;  and  it  is  most  important  that  when  the 
selection  of  a  proprietary  food  under  such  circumstances  is  to  be  made, 
the  physician  should  be  fully  cognizant  of  its  composition  and  what  may 
be  expected  from  it. 

There  are  a  number  of  preparations  on  the  market  consisting  almost 
entirely  of  starch,  or  of  some  form  of  sugar,  or  of  protein,  and  claiming 
nothing  else,  which  may  with  propriety  be  used  whenever  the  addition  of 
one  of  these  substances  to  a  milk-mixture  is  to  be  employed ;  and  if  these 
are  not  advertised  to  the  laity,  and  consequently  liable  to  be  givenfby 
the  mother  without  professional  advice,  no  objection  can  be  raised  to 
them. 

The  number  of  proprietary  foods  which  are  now  or  have  been  on  the 
market  is  vast;  and  it  would  be  a  waste  of  time  and  space  to  attempt  to 
consider  them  all.  Only  a  comparatively  few  will  be  referred  to,  in 
order  that  the  reader  may  have  some  idea  of  their  actual  composition 
and  mode  of  manufacture.  The  analytical  tables  are  given  in  order  to 
show  how  closely,  or  oftener  how  remotely,  they  resemble  human  milk  in 
composition.  Some  of  the  foods  are  still  actively  employed;  of  others 
little  is  now  heard. 

The  various  proprietary  foods  may  be  classified  as  follows : 

I.  Condensed  Milks. — These  consist  of  whole  or  skimmed  milk  con- 
densed by  evaporating,  and  often  with  the  addition  of  cane-sugar. 

II.  Malted  or  Dextrinized  Foods. — The  basis  of  these  is  starch  which 
has  been  completely  converted.  To  some  of  them  milk  has  been  added 
in  the  process  of  manufacture.     A  few  have  still  other  additions. 

III.  Amylaceous  Foods. — These  are  composed  entirely  or  partly  of 
unconverted  starch.  Quite  commonly  it  is  recommended  that  they  be 
mixed  with  milk.  Milk  and  milk-sugar  have  been  added  in  the  process 
of  manufacture  of  some  of  them. 

IV.  Miscellaneous  Foods. — Infant-foods  often  with  milk  as  a  basis 
with  the  addition  of  other  substances  than,  or  in  addition  to,  starch  or 
sugar.     They  are  incompletely  or  not  at  all  dextrinized. 

V.  Protein  Foods. — These  consist  of  commercial  foods  claimed  to  be 
especially  rich  in  protein.  They  are  not  primarily  intended  for  use  in 
infancy,  but  are  often  of  temporary  benefit. 

I.  Condensed  Milks. — These,  including  the  so-called  "dried  milks" 
and  "evaporated  creams,"  are  made  by  evaporating  the  milk  by  heat 
to  a  greater  or  less  degree  and  then  sealing  it  in  cans.  All  of  them  need 
much  dilution  with  water  before  they  can  be  employed. 

They  may  be  divided  into : 

1.  Dried  Milk. — This  is,  in  fact,  a  condensed  milk,  but  not  in  the 
usual  commercial  sense  of  the  term.  None  of  the  condensed  milks,  as 
ordinarily  designated,  have  been  condensed  to  the  degree  of  actual  dryness. 
There  are  various  preparations  of  dried  milk  upon  the  market  sold  under 
different  names.  Some  of  them  are  made  from  whole  milk;  others  from 
skimmed  milk.  The  analysis  given  on  p.  162  readily  shows  to  which  of 
these  two  classes  each  belong.  Mammala  is  produced  from  skimmed 
milk,  with  the  addition  of  lactose. 

2.  Unsweetened  and  Condensed  Whole  Milk.^ — In  this  form  nothing 
has  been  removed  by  skimming  and  nothing  added.  It  is  simply  a 
condensed  whole  milk.     It  keeps  badly  after  the  receptacle  is  opened. 

3.  Sweetened  and  Condensed  Whole  Milk.^ — ^In  this  instance  from  40 
to  45  per  cent,  of  saccharose  has  been  added  in  the  course  of  preparation 
for  the  purpose  of  preserving  the  milk. 

11 


162 


THE  DISEASES  OF  CHILDREN 


4.  Sweetened  and  Condensed  Skimmed  Milk. — Here  the  milk  has 
had  the  fat  removed,  and  cane-sugar  added  as  in  the  previous  form. 

All  the  condensed  milks  are  unsuitable  for  infant-feeding.  When 
properly  diluted  with  water  the  ingredients  still  retain  at  the  best  the 
normal  relationships  of  cow's  milk.  They  are  all  deficient  in  the  amount 
of  fat  required  by  the  normal  infant  after  the  protein-percentage  has 
been  properly  reduced.  They  may  be  used  temporarily  when  a  very  low- 
fat  food  is  required,  but  offer  no  advantages  over  a  dilution  of  fresh 
whole  milk.  The  large  amount  of  sugar  in  the  sweetened  condensed  milk 
makes  the  food  so  sweet  that  it  could  not  be  taken  unless  diluted  to 
such  a  degree  that  the  nourishing  qualities,  except  for  the  sugar,  are  en- 
tirely inadequate.  The  4th  class  in  addition  to  the  sweetening  contains 
almost  no  fat,  and  is  entirely  unfitted  for  administration  to  infants. 

The  following  table  gives  the  percentage-composition,  derived  from 
various  sources,  of  several  of  the  condensed  milks.  These  examples  are 
drawn  at  random  from  the  recorded  analyses  in  my  possession  of  over 
50  different  varieties.     Some  of  thein  are  now  used  little  if  at  all. 

In  this,  as  in  the  succeeding  tables,  the  analysis  of  human  milk 
heads  the  list,  for  the  convenience  of  comparison. 

Table  53. — Analyses  of  Condensed  Milks 


Water 


Fat 


Protein 


Lactose      Saccharose 


Mineral 
matter 


Human  Milk . 


Dried  Milk. 

GlaxQi 

Defiance^ 

Lacvitum^ .... 
Dry  CO  Brand  ^ 
Mammala^. . . . 


87-88 


3.50 
4.90 
5.34 
3.00 
5.00 


Condensed  Whole  Milk. 

IdeaP 68.27 

St.  Charles'^ 66.46 

Highland^ 68.75 

First  Swiss" 62.15 

Hollandia' I  57.00 


Sweetened    Condensed    Whole' 
Milk. 

Rose* 

Red  Cross* 

Eagle* 

Anglo-Swiss' 

N6stle's  Condensed  milk*. 


23.70 
25.97 
30.16 
25.60 


3.5-4 


27.40 
27.00 
29.40 
12.00 
12.00 


10.10 
9.26 
9.63 

11.38 
9.80 


11.00 

7.93 

7.51 

10.80 

26.30      11.50 


Sweetened  Condensed  Skimmed 
Milk. 

CowsUp9 j  25.68  ;     0.71 

Farm* '•  28.48  '     0.60 

Snake' '  25.88  '     0.96 


1-1.5 


22.20 
26.20 
28.04 
34.00 
24.00 


7.36 

10.49 

9.21 

9.90 

11.30 


9.70 
8.91 
8.40 
8.80 
9.70 


10.35 

7.90 

10.64 


6.5-7 


41.00 
36.30 
31.26 
44.00 
55.00 


11.03 
12.24 
10.89 
14.44 
18.50 


14.60 
11.93 
9.82 
16.00 
13.00 


16.85 
18.76 
27.38 


38.70 
43.77 
42.24 
37.10 
37.50 


43.09 
41.77 
34.07 


.20 


5.90 
5.60 
5.96 
7.00 
5.00 


1.85 
1.55 
1.52 
2.10 
3.40 


2.30 
1.49 
1.87 
1.70 
1.90 


2.48 
2.04 
2.56 


1  Hutchison,  Food  and  Dietetics,  1911,  467. 

2  Ibid.,  p.  119. 

^  Cautley,  Sutherland's  System  of  Diet  and  Dietetics,  1908,  223. 

■•  Advertisement. 

*  Penna.  Dept.  of  Agriculture  Bulletin  No.  10. 

®  Cautley,  loc.  cit.,  p.  218. 

''  Hutchison,  loc.  cit.,  p.  463. 

8  Cautley,  loc.  cit.,  p.  220. 

9  Chapin,  Infant  Feeding,  1902,  79. 


PROPRIETARY  FOODS 


163 


Condensed  milks  are  generally  diluted  with  from  9  to  20  parts  of  water 
before  using.  Assuming  a  dilution  of  1  in  10  as  convenient  for  calcula- 
tion, we  may  readily  see  what  a  weak  food,  except  for  the  sugar,  is  ob- 
tained, and  can  understand  why  condensed  milk  so  often  agrees  with 
the  digestion,  but  either  does  not  support  the  infant,  or  allows  it  to  grow 
flabbily  fat  without  proper  tissue,  as  a  result  of  the  relatively  large 
amount  of  sugar  present  and  the  small  amount  of  protein.  A  dilution 
of  1  in  10,  for  instance,  of  Eagle  Brand  Condensed  Milk,  produces  a 
food  containing  only  fat  0.75  per  cent.,  protein  0.84  per  cent.,  sugar 
5.21  per  cent,  and  salts  0.18  per  cent. 

II.  Dextrinized  (Malted)  Foods. — The  basis  of  these,  often  called 
also  Liebig's  Foods,  is  starch  usually  derived  from  wheat-flour  or  barley- 
flour  which  has  been  entirely  converted  into  soluble  carbohydrates, 
generally  by  the  action  of  the  diastase  of  a  malt-extract.  These  carbo- 
hydrates consist  of  dextrin  and  maltose  and  intermediate  substances. 
The  foods  should  not  give  the  iodine  reaction  for  unconverted  starch. 
To  some  of  them  milk  is  added  in  the  process  of  manufacture.  To 
others  it  is  to  be  added  when  the  food  is  mixed  for  the  child.  The  quan- 
tity of  sugar  present  is  far  too  great  to  resemble  in  any  way  human  milk, 
and  it  is  to  be  noted  also  that  it  is  not  the  natural  sugar  of  the  milk  which 
is  employed.  When  diluted  sufficiently  to  reduce  the  sugar  to  a  normal 
amount  the  foods  are  all  much  too  weak  in  the  percentage  of  fat,  and 
often  of  protein  as  well,  unless  fresh  milk  or  cream  is  added.  These  facts 
can  be  seen  by  examining  the  figures  in  the  following  table,  which  gives 
the  analysis  of  a  few  of  the  foods  of  this  class.  There  is  no  real  need  for 
any  of  these  foods,  inasmuch  as  a  milk-mixture  with  either  the  addition 
of  starch  dextrinized  at  home  or  of  a  dextrin-maltose  preparation  which 
is  not  called  a  food,  can  be  more  conveniently,  cheaply  and  accurately 
prepared  in  the  house. 


Table  54. — Analyses  of  Dextrinized 

Foods 

j  Water 

Soluble 
Fat       Protein       carbo- 
hydrates 

Mineral 
matter 

Remarks 

Human  milk 87-88 

Horlick's  Malted  Milk'.       3.06 

Liebe's  Soluble  Food'..  . '  22.34 

Loeflund'8  Infant  Food'     25.37 

Loeflund's     Peptonized 
Infant  Milk' 20.39 

3.5-4 

8.78 

Trace 

Trace 

8.46 
0.16 

17.00 

1-1.5 
16.35 

6.47 

4.17 

10.13 
10.35 

18.00 

1.10 

6.5-7 
67.95 

68.80 

68.60 

57.53 
79.57 

55.00 

93.95 

0.2 
3.86 

1.71 

i.« 

3  05 

Milk;     barley     and     wheat 
malted. 

An  extract  of  malt  made  from 
wheat. 

Wheat  and  malt. ' 

Practically  a  malt-extract. 

Wheat,    malted    barley 'and 
bicarbonate  of  potash. 

A  combination  of  whole-milk 
with  dextrinized  wheat. 

Dextrinized  cereals. 

Mellin's  Food' 5.62 

Laibose' " 1     6.00 

Ju8tfood» 4.50 

2.30 
4.00 
0.32 

III.  Amylaceous  Foods.^ — ^All  of  these  contain  unconverted  starch 
in  larger  or  smaller  amount.  In  some  of  them  malt-extract,  pancreatic 
extract  or  some  form  of  sugar  has  been  added;  l)Ut  in  none  of  them, 

'  Advertisement  and  information  from  mnnufarturcr. 
-  BlnuhorK,  Arch.  f.  Ilyg..  1807,  XXX,  125. 
>  .\dvcrtiHcnient. 


164 


THE  DISEASES  OF  CHILDREN 


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PROPRIETARY  FOODS  165 

according  to  the  analyses,  is  the  starch  entirely  transformed.  In  the 
case  of  many  of  them  it  is  admitted  to  be  present  and  the  food  is  intended 
to  be  added  to  milk-mixtures.  In  others  the  food  is  recommended  with- 
out any  statement  regarding  the  presence  of  starch,  or  even  with  the  claim 
that  none  exists  in  it.  The  accompanying  table  gives  published  analyses 
of  a  number  of  starch-containing  foods  on  the  market. 

IV.  Miscellaneous  Foods. — In  this  class  are  placed  a  number  of 
foods  in  the  composition  of  which  other  substances  than  starch  or  sugar 
have  been  used,  or  which  in  some  way  do  not  properly  belong  to  any  of 
the  previous  classes.  In  some  the  proportion  of  cream  is  increased  either 
by  direct  addition  of  this  or  by  removal  of  a  part  of  the  protein,  and,  the 
food  being  afterward  condensed,  the  title  of  condensed  cream  might  with 
propriety  be  employed.  Some  are  malted  or  peptonized;  in  some 
unconverted  starch  is  present,  and  the  food  might  be  placed  among  the 
amylaceous  preparations  were  it  not  for  the  addition  of  other  substances. 
The  accompanying  table  gives  published  analyses  of  some  of  them. 

V.  Proteid  or  Nitrogenous  Foods. — These  form  a  mixed  group 
in  all  of  which  the  nitrogenous  element  is  claimed  to  be  high  as  compared 
with  other  ingredients.  They  are  not  intended  to  be  permanent  substi- 
tutes for  human  milk  and  some  of  these  fill  a  useful  place.  They  may 
be  divided  into  (1)  beef -extracts,  (2)  beef-juices,  (3)  peptonized  meat 
preparations,  (4)  other  proteid  foods. 

1.  The  Commercial  Beef-extracts. — These,  although  popularly  sup- 
posed to  be  highly  nourishing  from  the  amount  of  protein  contained,  pos- 
sess in  reahty  but  a  small  percentage  of  this,  while  the  extractive  matter 
and  salts  are  present  in  large  amount.  They  are  prepared  under  the 
influence  of  water,  heat  and  pressure.  Some  of  the  muscle-fibre  which 
remains  is  added  and  the  liquid  then  evaporated.  Only  those  in  which 
the  fibre  has  been  thus  used  contain  an  amount  of  protein  worth  consider- 
ing. A  table  of  analyses  of  a  number  of  them  pubHshed  by  Hutchison^ 
shows  a  total  percentage  of  soluble  protein  varying  in  round  numbers 
from  3  to  33  per  cent.  As  only  small  doses  are  customarily  given,  or 
could,  indeed,  be  tolerated  on  account  of  the  excess  of  mineral  matter 
and  extractives,  the  amount  of  protein  received  by  the  infant  is  in  reahty 
trifling;  given  in  doses  of  a  few  drops,  as  is  often  done,  either  alone  or  in 
addition  to  the  milk  in  the  bottle. 

2.  Beef-juices. — These  consist  of  expressed  juice  or  serum  of  the 
beef.  According  to  analyses  of  a  number  of  the  commercial  preparations, 
as  published  by  Hutchison,  ^  the  percentage  of  coagulable  protein  varies 
from  17  per  cent,  to  0.3  per  cent.,  nearly  all  of  those  in  his  hst  containing 
not  over  5  per  cent.  Although  some  of  them  are  richer  in  protein  than 
is  freshly  prepared  beef-juice,  yet,  as  in  the  case  of  the  beef-extracts, 
the  salts  and  extractive  matter  are  generally  present  in  too  large  an 
amount  to  permit  of  the  giving  them  in  sufficient  quantity  to  be  of  real 
benefit.  My  preference  has  always  been  decidedly  for  the  freshly  pre- 
pared beef-juice  (p.  150). 

3.  Beef-powders  and  Peptonized  Beef-preparations. — Some  of  these 
are  extensively  employed  for  temporary  use  in  infant-feeding  and  infant- 
therapeutics.  Prominent  among,  them  are  a  number  whose  nitrogenous 
value  is  shght  and  whose  percentage  in  alcohol  is  high.  On  account  of 
their  comparatively  pleasant  taste  they  may  be  used  in  place  of  other 

1  Food  and  Dietetics,  1911,  9G. 
^Loc.  cit.,  100. 


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PROPRIETARY  FOODS  167 

alcoholic  stimulants  in  infancy  and  childhood.     The  following  analyses 
are  given  by  Harrington.^ 

T-^LB  57. — Alcoholic  Strengths  of  Liquid  Beef-preparations 


Alcohol  by  volume, 
per  cent. 


Total  solids, 
per  cent. 


Liquid  Peptonoids 

Panopeptone 

Hemapeptone 

Nutritive  Liquid  Peptone . . 

Hemaboloids 

Tonic  Beef 

Mulford's  Predigested  Beef. 


23.03  14.91 

18.95  17.90 

10.60  !  19.54 


14.81 
15.81 
15.58 
19.72 


15.20 

6.36 

18.16 

10.39 


4.  Other  Proteid  Foods. — Among  other  preparations  the  following 
may  be  mentioned : 

Mosquera's  heef-jelly^  which  contains  28.63  per  cent,  of  protein  in  a 
partially  digested  state. 

Somatose. — A  meat-powder  completely  peptonized  and  containing 
over  80  per  cent,  of  protein  (Neumann.)^  Another  form,  Milk  Somatose, 
is  derived  from  milk  and  contains  about  70  per  cent,  of  protein  (Neu- 
mann).    Somatose  is  often  useful  as  an  addition  to  milk. 

Dry  Peptonoids.'^ — This  contains  40  per  cent,  of  protein,  the  remainder 
of  its  nutritive  value  depending  entirely  on  carbohydrates  (51.5  per  cent.). 

Tropon. — A  powder  rich  in  protein  (90.44  per  cent.  (Frohner  and 
Hoppe)^  derived  both  from  animal  and  vegetable  sources.  It  is  not 
predigested. 

Rohorat. — A  food  in  powdered  form  made  from  various  grains  and 
containing  about  95  per  cent,  of  vegetable-albumin  (Sommerfeld).^ 

Hygiama. — A  powder  giving  21.93  per  cent,  of  nitrogenous  substance 
as  well  as  a  high  percentage  of  carbohydrate,  most  of  which  is  in  soluble 
form.     It  is  flavored  with  cocoa  (Kraus).'' 

Plasmon  represents  in  powdered  form  75  to  80  per  cent,  of  albumin 
derived  from  milk,  with  the  addition  of  5  to  7  per  cent,  of  carbonate  and 
bicarbonate  of  soda.     It  is  in  reality  an  alkali-casein  (Laves). ^ 

Nutrose. — A  powdered  food  formed  of  a  soda-combination  with  casein. 
It  possesses  73.68  per  cent,  of  albumin  and  11.67  per  cent,  of  water 
(Neumann).^ 

Soson. — A  meat-derivative  containing  92.5  per  cent,  albumin  (Neu- 
mann).^" 

Eucasin. — A  powdered  preparation  of  casein  consisting  of  77.60  per 
cent,  of  nitrogenous  material  (Konig).^^ 

Forsan. — A  powdered  product  made  of  beef-blood.  It  contains  84 
per  cent,  of  nitrogenous  material  (Konig).^- 

1  Boston  Med.  and  Surg.  Journ.,  1903,  Mar.  12,  283. 

2  Wylie,  Foods  and  Their  Adulterations,  1911,  566. 
'  Miinch.  med.  Wochenschr.,  1893,  395. 

*  Advertisement,  Arlington  Chemical  Co. 

^Miinch  med.  Wochenschr.,  1899,  52. 

«  Archiv  flir  Kinderheilk  .  1903,  XXXVI,  341. 

^  Tlierap.  Monatsh.,  1902,  XVI,  035. 

8  Miinch.  med.  Wochenschr.,  1900,  XL VII,  1339. 

Umc.  cit.,  72. 
'0  Lnc.  cit.,  106. 

"  Nahrungs-  u.  Genussmittel,  1904,  II,  539. 
•'^  Loc.  cit. 


168  THE  DISEASES  OF  CHILDREN 

Alhulactin}  is  a  grey-white  powder  consisting  chiefly  of  lactalbumin, 
and  having  83.60  per  cent,  of  protein.  It  may  be  added  in  small  amounts 
to  mixtures  of  cow's  milk. 

Larosan. — This  preparation,  devised  by  Stoltzner,^  is  a  pure  calcium 
caseinate  containing  the  equivalent  of  2.5  per  cent,  of  calciimi  oxide. 
It  was  devised  to  simphfy  the  process  of  preparing  casein  milk.  When 
2  per  cent,  of  it  is  added  to  equal  parts  of  milk  and  water,  it  gives  a  mix- 
ture containing  fat  1.75  per  cent.,  sugar  2.25  per  cent.,  protein  3.45  per 
cent.,  phosphoric  oxide  0.122,  calcium  oxide  0.136.  The  mixture  has  the 
advantage  that  it  can  be  boiled.  It  is  frequently  an  excellent  and  con- 
venient substitute  for  casein  milk. 

Hoos'  Albumin  Milk.^ — This  consists  of  a  dried  casein-milk  of  a 
strength  and  composition  to  reproduce  when  diluted,  the  original  for- 
mula of  Finkelstein.  As  supphed  in  the  can  it  contains  protein  38  per 
cent,  fat  30  per  cent,  milk-sugar  19  per  cent.,  salts  5  per  cent.  As  with 
the  freshly  prepared  casein-milk,  sugar  in  some  form  will  need  to  be  added 
after  the  infant's  disturbances  of  digestion  are  relieved. 

Sanatogen  (Treat). ^ — This  is  a  preparation  containing  about  90  per 
cent,  of  casein,  with  sodium-glycerophosphate  and  a  small  amount  of 
unidentified  nitrogenous  compound.  It  would  appear  to  possess  no 
advantage  over  the  very  much  cheaper  commercial  casein. 

1  Advertisement,  Analytical  Report,  Lancet,  1911,  I,  34. 

2  Munch,  med.  Wochenschr.,  1913,  LX,  291. 

2  Advertisement  and  information  received  from  manufacturer. 
*  Journ.  Amer.  Med.  Assoc,  1914,  LXIII,  1831. 


CHAPTER  VII 

DIET  AFTER  THE  FIRST  YEAR 
DIET  FROM  12  TO  18  MONTHS 

By  the  time  the  infant  is  1  year  old  it  will  have  been  weaned  and  be 
fed  upon  cow's  milk  nearly  or  quite  undiluted,  and  it  should  have  com- 
menced to  take  a  certain  amount  of  starchy  material  in  the  milk  (p.  152). 
From  this  age  its  diet  is  gradually  extended.  It  is  better  first  to  increase 
the  amount  of  starch  by  having  the  child  learn  to  eat  stale  bread  or  toast 
moistened  with  milk  and  fed  from  a  spoon;  a  well-cooked  porridge  of 
farina,  oatmeal,  hominy  or  wheaten  grits,  arrowroot,  sago,  tapioca,  etc., 
one  not  of  oatmeal  being  the  first  to  be  tried;  or  some  form  of  the  nu- 
merous excellent  farinaceous  breakfast  foods  on  the  market,  those  which 
require  cooking  being  much  to  be  preferred.  All  the  porridges  must 
be  seasoned  with  salt  in  their  preparation  or  before  use,  a  small  amount 
of  milk  poured  over  them,  and  a  Uttle  cane-sugar  added,  if  necessary,  to 
make  the  infant  eat  them.  They  may  be  made  from  the  grain  or  from 
the  flour,  using  about  4  level  tablespoonfuls  to  the  pint  of  milk  or  water. 
The  boiling  must  be  slow  and  continue  for  from  3  to  6  hours  for  broken 
grain,  and  at  least  3^  hour  for  flours.  The  porridge  may  with  advantage 
be  employed  for  the  midday  meal,  the  other  meals  still  consisting  of  milk. 
Very  shortly  it  may  instead  be  given  for  breakfast,  and  for  dinner  the 
child  may  receive  bread  or  well-boiled  rice,  moistened  with  beef-juice 
or  with  dish  gravy  as  free  as  possible  from  fat.  Soft-boiled  eggs  may 
be  tried  at  about  the  age  of  15  months,  taking  pains  that  the  white  is  not 
firmly  coagulated,  and  remembering  that  many  children  do  not  tolerate 
eggs  at  all  well  until  after  the  18th  or  20th  month,  and  others  not  even 
then  unless  given  them  only  occasionally.  All  through  this  period  milk 
should  remain  the  principle  article  of  diet,  and  care  with  regard  to  its 
bacterial  content  continued.  Yet  precautions  must  be  taken  that  milk 
is  not  practically  the  only  food  ingested,  but  that  as  the  amount  of  solid 
food  is  increased  that  of  the  milk  be  reduced  somewhat.  The  more  milk 
there  is  poured  upon  the  porridge,  the  less  should  be  drunk  from  the  cup. 
A  total  of  from  24  to  32  oz.  should  usually  be  the  outside  daily  limit. 
The  milk  may  be  slightly  or  not  at  all  diluted,  or  may  have  a  small 
amount  of  some  cereal  jelly  added  to  each  bottle.  If  it  is  from  Jersey 
cattle  the  removal  of  some  of  the  cream  is  advisable.  Very  many  in- 
fants in  the  2d  year  do  not  tolerate  undiluted  milk,  especially  if  it  is 
rich  in  cream.  Somewhere  between  12  and  18  montlis  of  age  the  infant 
should  have  been  taught  to  take  most  of  the  milk  from  a  cup  or  glass, 
inasmuch  as  it  is  very  difficult  to  combine  the  eating  of  solid  food  at 
meal-time  with  the  drinking  of  milk  from  a  bottle.  The  milk  from  the 
bottle  will  be  taken  without  pause  and  the  desire  for  solid  food  inter- 
fered with;  or  if  the  bottle  is  given  last,  the  child  takes  too  much  nourish- 
ment for  one  meal.  An  exception  may  be  made,  if  desired,  as  regards 
the  bottle  before  the  moining  nap  and  that  at  9  or  10  p.m.  In  the  case 
of  many  infants  the  juice  from  a  small  orange,  or  that  of  well-stewed 

109 


170  THE  DISEASES  OF  CHILDREN 

prunes,  may  properly  be  added  to  the  dietary.  These  aid  in  avoiding 
constipation,  and  prevent  the  development  of  scm'vy,  but  neither  of 
them  can  be  considered  indispensable  articles  of  diet  for  healthy  children. 
Orange-juice  may  be  given  an  hour  before  one  of  the  feedings.  Some- 
times it  is  useful  to  begin  it  toward  the  end  of  the  1st  year  or  even  before 
this. 

The  following  hst  may  be  followed  as  a  guide  for  the  feeding  of 
children  from  12  to  18  months  of  age.     A  numbered  selection  of  dietaries 

is  given. 

« 

Table  58. — Diet  From  1  Year  to  18  Months 

Breakfast  (6  to  7  a.m.);  (1)  8  to  10  oz.  of  milk  with  stale  bread,  toast  or  zweiback 
broken  into  it.  (2)  2  to  3  tablespoonfuls  of  well-cooked  oatmeal,  arrowroot,  wheaten 
grits,  hominy  grits,  farina,  etc.,  or  one  of  the  numerous  good  breakfast  foods  on  the 
market,  not  of  the  ready-to-serve  class,  made  into  a  well-cooked  unstrained  porridge, 
and  with  6  to  8  oz.  of  milk  poured  over  it.  (3)  A  soft-boiled  or  poached  egg  (after 
15  months)  with  stale  bread  thinly  buttered,  and  a  cup  of  milk. 

Second  Meal  (10  a.m.)  :  8  or  10  oz.  of  milk  from  a  cup  or  bottle. 

Dinner  (1:30  to  2  p.m.):  (1)  Stale  bread  moistened  with  dish-gravy  (no  fat), 
beef -tea,  or  1  to  2  oz.  of  beef-juice;  a  cup  of  milk.     (2)  Rice  or  grits  moistened  in  the 
same  way;  6  to  8  oz.  of  milk.     (3)  A  soft-boiled  egg  and  stale  bread  thinly  buttered; 
6  to  8  oz.  of  milk.     Sago,  tapioca,  or  rice  pudding  (no  raisins),  junket,  or  cornstarch  in  • 
small  quantities  as  dessert  with  any  of  these  diets. 

Fourth  Meal  (5  to  6  p.m.)  :  8  to  10  oz.  of  milk;  or  some  bread  and  milk. 

Fifth  Meal  (9  to  10  p.m.)  :  8  to  10  oz.  of  milk  from  a  cup  or  bottle. 

This  list  is  intended  as  suggestive  only.  It  is  also  one  to  which  the 
child  must  grow  accustomed  very  gradually,  and  it  represents  the  extreme 
of  what  may  be  given  rather  than  what  must  necessarily  be  eaten.  Many 
infants  do  well  with  a  dietary  very  much  weaker  than  this.  Inasmuch 
as  the  daily  amount  of  milk  is  now  restricted,  care  must  be  taken  that 
the  child  receive  water.  The  milk  should  not  be  used  as  a  drink  to 
replace  this  in  order  to  quench  thirst.  If  it  is  desired,  a  cup  of  broth 
may  take  the  place  of  milk  at  dinner;  but  there  is  usually,  in  my  experi- 
ence, no  advantage  in  this,  and  it  can  well  be  dispensed  with  until  after 
the  age  of  18  months.  The  number  of  teeth  which  have  been  cut  should 
have  little  influence  upon  the  selection  of  the  food  during  this  period, 
since  the  infant  does  but  little  masticating  in  any  event.  The  weight  and 
general  condition  are  better  guides. 

DIET  FROM  18  MONTHS  TO  2  YEARS] 

During  this  period  but  little  change  is  made  in  the  dietary.  Milk 
is  still  a  standby,  and  should  have  the  same  precautions  against  contamina- 
tion taken  with  it  as  earher  in  the  infant's  life,  but  the  quantity  is  being 
diminished  by  the  employment  of  more  soHd  food.  Potatoes  may  be 
given  occasionally  for  dinner,  although  the  starch  of  this  vegetable  seems 
often  less  digestible  than  some  other  varieties.  Finely  minced  meat  is 
also  advisable.  Orange-juice,  well-stewed  prunes  mashed  through  a 
sieve,  and  well-baked  apple  taken  with  little  or  no  sugar,  are  useful 
additions.  It  is  the  growing  custom  to  begin  the  employment  of  green 
vegetables  by  this  time;  sometimes  even  earlier.  This  can  be  done 
cautiously  and  is  often  beneficial,  especially  where  a  tendency  to  con- 
stipation exists.  The  vegetables  should  be  thoroughly  cooked,  or,  better, 
well-steamed  to  favor  the  retention  of  the  salts  (Bartlett),^  and  then 
rubbed  through  a  fine  sieve.     Some  children  assimilate  food  of  this  sort 

1  Arch,  of  Pediat.,  1917,  XXIV,  436. 


DIET  FROM  TWO  TO  THREE  YEARS  171 

readily;  others  find  difficulty  in  digesting  it  even  at  a  decidedly  later 
period.  The  fifth  meal  is  no  longer  desirable.  The  following  list  is, 
like  the  last,  a  guide  only. 

Table  59. — Diet  from  18  Months  to  2  Years 

Breakfast  (7  a.m.):  (1)  8  oz.  of  milk  with  a  slice  of  buttered  bread  or  toast,  or 
a  soda,  oatmeal  or  other  unsweetened  biscuit.  (2)  A  soft-boiled  or  poached  egg, 
with  bread  and  butter  and  6  to  8  oz.  of  milk.  (3)  Porridge  as  described  in  the  previous 
Ust. 

Second  Meal  (10  a.m.)  :  (1)  Bread  broken  in  milk.  (2)  Bread  and  butter  or  a  soda 
or  other^biscuit  with  6  to  8  oz.  of  milk. 

Dinner  (2  p.m.):  (1)  Boiled  rice  or  a  baked  potato  mashed  and  moistened  with 
dish-gravy  or  beef -juice;  or  from  J^  to  1  tablespoonful  of  spinach,  string-beans,  peas, 
asparagus  tips  or  carrots ;  6  oz.  of  milk.  (2)  Six  ounces  of  mutton  or  chicken  broth  with 
barley  or  rice  in  it  and  the  meat-fibre  remaining  (see  p.  151);  some  bread  and  butter, 
and  .some  sago  or  rice-pudding.  (3)  A  small  portion  (2  or  3  teaspoonfuls)  of  minced 
white  meat  of  chicken,  turkey,  rare  beef  or  beef-steak,  lamb,  mutton,  or  fish;  bread  and 
butter;  8  oz.  of  milk.  A  baked  apple,  or  a  few  stewed  prunes  pressed  through  a  colan- 
der may  be  allowed  as  dessert  with  some  of  these  dietaries  at  the  meals  when  green 
vegetables  are  not  given. 

Fourth  Meal  (6  p.m.):  (1)  Bread  and  milk.  (2)  Milk  with  soda  or  other  biscuit, 
toast,  zweiback,  or  bread  and  butter.  (3)  Two  or  3  tablespoonfuls  of  a  cereal-porridge 
with  8  oz.  of  milk. 

DIET  FROM  2  TO  3  YEARS 

Meat  which  is  ipjer^ly  cut  up,  not  scraped  or  minced,  is  now  added  to 
the  list.  Stewed  fruit  in  greater  quantities  can  be  used,  and  many  fresh 
fruits  if  ripe  are  excellent,  such  as  peaches,  grapes  without  seeds  and 
raspberries.  Bananas  should  be  given  not  at  all,  and  strawberries  very 
cautiously  and  only  if  sweet  and  quite  ripe.  There  is  generally  not  the 
same  need  for  specially  germ-free  milk  of  definite  percentage-strength 
as  existed  earher  in  life,  although  precautions  should  still  be  taken  to 
obtain  a  good  and  pure  article.  A  total  of  24  ounces  daily  should  be 
sufficient  and  it  should  not  be  rich  in  fat.  It  should  have  the  chill 
removed,  but  need  not  be  actually  warm.  Selected  green  vegetables 
should  now  certainly  be  added  to  the  dietary,  if  they  have  not  been 
given  previously. 

The  following  hst  is  a  guide  for  this  period. 

Table  60. — Diet  From  2  to  3  Years 

Breakfast  (7  to  8  a.m.):  (1)  A  small  portion  of  beef-steak,  with  2  to  3  tablespoon- 
fuls of  farina,  oatmeal,  hominy-grits,  wheaten  grits,  corn-meal,  or  other  cereal- 
porridge  with  6  or  8  oz.  of  milk  upon  it.  (2)  A  soft  boiled  egg;  bread  and  butter, 
and  6  or  8  oz.  of  milk. 

Second  Meal  (11  a.m.)  :  8  oz.  of  milk,  with  bread  and  butter  or  with  a  soda  or  other 
biscuit.     (2)  Bread  and  milk.     (3)  Six  ounces  of  chicken  or  mutton  broth. 

Dinner  (2  p.m.):  Roasted  fowl,  mutton,  or  beef  cut  fine;  mashed  l)aked  potato, 
rice,  or  macaroni,  with  butter  or  dish-gravy  on  it;  bread  and  butter,  a  green  vegetable 
of  the  sort  and  prepared  in  the  manner  described.  As  dessert,  tapioca,  sago,  or  rice- 
pudding,  junket,  or  some  of  the  fruits  mentioned. 

Supper  (6  p.m.):  (1)  Broad  and  butter.  (2)  Eight  ounces  of  milk,  with  soda 
or  similar  biscuit,  or  with  bread  and  ])utter.  (3)  Two  to  4  tablespoonfuls  of  a  coroai- 
porridge,  with  8  oz.  of  milk.  (4)  A  soft-boiled  egg  with  bread  and  butter.  It 
makes  a  pleasant  variation  to  give  the  egg  for  supper  on  some  daj's  and  for  Ijroakfast 
on  others;  but  it  should  not  be  allowed  twice  a  day. 

Again  must  be  emphasized  the  statement  made,  that  these  tables  are 
a  guide  only,  not  an  absolute  rule,  and  that  they  represent  rather  the  ex- 
treme than  the  requirements  of  the  dietary. 

No  increase  of  diet  should  be  made  in  the  midst  of  a  heated  term  unless 
it  is  absolutely  necessary.     Indeed,  it  is  better  in  very  hot  weather  to 


172  THE  DISEASES  OF  CHILDREN 

return  to  one  suitable  for  a  much  younger  child,  and  to  let  it  be  largely  of 
milk,  diluted  more  than  usual.  It  is  sometimes  advisable  to  use  a  small 
amount  of  cream  upon  the  cereal-porridge.  In  my  own  experience 
healthy  children  are  better  without  it.  Very  many  children  exhibit 
great  difficulty  in  digesting  much  starchy  food;  and  others,  as  stated, 
show  some  degree  of  intolerance  for  egg.  In  such  cases  meat  may  occa- 
sionally be  allowed  for  breakfast  as  well  as  for  dinner.  As  a  rule, 
however,  meat  should  be  given  but  once  a  day.  The  ready-to-serve 
cereals  may  be  given  occasionally,  but  should  be  avoided  as  a  steady  diet. 
At  the  outbreak  of  any  acute  illness,  especially  of  the  digestive  apparatus, 
the  diet  should  be  very  greatly  reduced  in  variety  and  amount.  Of 
course,  the  existence  of  a  chronically  weak  digestion  modifies  greatly 
all  the  schemes  for  diet  which  have  been  detailed.  There  is  no  good 
foundation  for  the  popular  fear  of  the  ''second  summer,"  provided  the 
diet  be  watched  then  with  the  same  care  as  in  the  first  summer.  A 
child  which  has  been  breast-fed  has  had  the  advantage  in  its  first  summer 
of  being  upon  its  natural  food;  and  it  is  on  this  account  that  the  "second 
summer"  has  acquired  a  bad  reputation. 

Thorough  mastication  and  slowness  of  eating  must  be  taught  as 
early  as  possible,  but  it  is  difficult  to  obtain  this.  Neither  before  the 
age  of  3  years  nor  after  it  should  food  be  allowed  between  meals,  unless 
there  is  actual  hunger,  and  then  the  habit  of  irregular  eating  must  not 
be  allowed  to  form.  Allowing  the  child  to  go  hungry  on  a  few  occasions 
will  often  get  it  in  the  way  of  eating  more  heartily  at  its  regular  meal- 
times. During  temporary  loss  of  appetite  eating  should  not  be  urged, 
since  the  child  may  be  merely  following  Nature's  demands  for  a  rest  of 
the  digestive  organs.  Care  should  be  taken,  too,  not  to  put  too  much 
sugar  upon  cereal-gruels.  A  very  httle  may  be  used,  but  it  is  better'  to 
accustom  the  child  to  take  them  without  sugar. 

The  meals,  up  to  about  the  age  of  2}y^  years,  are  best  given  in  the 
nursery,  but  from  this  time  the  child  can  well  sit  at  the  table  in  its  high 
chair,  or  at  a  small  table  close  by,  provided  that  it  never  be  given  articles 
of  food  not  suited  to  its  age. 

DIET  FROM  3  TO  6  YEARS 

From  3  years  onward  the  dietary  is  decidedly  increased  in  variety, 
approaching  more  closely,  although  gradually,  that  of  the  adult.  All 
rich,  highly  seasoned  dishes  are  to  be  avoided.  Milk,  not  rich,  must  still 
form  a  very  prominent  article  of  diet,  and  should  continue  to  do  so  up  to 
the  age  of  5  or  6  years  at  least.  Cream  should  be  employed  with  great 
caution  and  in  small  quantity.  The  heartiest  meal  should  be  in  the 
middle  of  the  day,  and  the  supper  should  be  light.  Meat  may  be  given 
once  or  twice  a  day,  depending  upon  the  needs  of  the  child  and  the  charac- 
ter of  its  digestion. 

The  following  lists  may  be  found  useful  as  a  guide. 

Table  61. — Foods  Permitted 

Meats. — Broiled  beef-steak,  lamb  chops  and  chicken;  broiled  liver;  roasted  or 
boiled  beef,  mutton,  lamb,  chicken  and  turkey;  broiled  or  boiled  fish. 

Eggs. — Soft-boiled,  poached,  scrambled,  omelette. 

Cereal  Foods. — Light  and  not  too  fresh  wheaten  and  Graham  bread,  toast,  zwie- 
back; plain  unsweetened  biscuit,  as  oatmeal,  soda,  water,  etc.;  hominy  grits,  wheaten 
grits,  corn-meal,  barley,  rice,  oatmeal,  macaroni,  etc. 

Soups. — Plain  soup  and  broth  of  nearly  any  kind. 

Vegetables. — White   potatoes,    boiled    onions,    spinach,    peas,    carrots,    asparagus 


AMOUNT  OF  FOOD  ELEMENTS  REQUIRED  AFTER  FIRST   YEAR     173 


except  the  hard  parts,  string  and  other  beans,  salsify,  lettuce,  stewed  celery,  young 
beets,  arrowroot,  tapioca,  sago,  etc. 

Fruits. — Xearly  all  if  stewed  and  sweetened;  of  raw  fruits,  used  moderately, 
peaches  are  one  of  the  best;  pears;  well-ripened  and  fresh  raspberries;  blackberries; 
grapes  without  the  skin  and  seeds;  oranges  without  the  rind. 

Desserts. — ^Light  puddings,  as  rice  pudding  without  raisins,  bread  pudding,  etc., 
plain  custards,  wine-jelly,  junket,  and  occasionally  ice-cream. 

Food  to  Be  Taken  With  Considerable  Caution 

Edney,  oysters,  muflBns,  hot  rolls,  sweet  potatoes,  baked  beans,  squash,  turnips, 
parsnips,  egg-plant,  stewed  tomatoes,  green  corn,  cherries,  plums,  raw  apples,  straw- 
berries, blueberries,  gooseberries,  currants. 

Foods  to  Be  Avoided 

Fried  food  of  any  kind,  griddle-cakes,  pork,  sausage,  ham,  goose,  veal,  corned-beef, 
pastry,  salt  fish,  highly  seasoned  foods,  all  heavy,  doughy,  or  very  sweet  puddings, 
unripe,  sour  or  wilted  fruit,  bananas,  pineapples,  cucumbers,  radishes,  raw  celery,  raw 
tomatoes,  cabbage,  cauliflower,  nuts,  candies,  sweet  cakes,  preserved  fruits,  jams,  tea, 
coffee,  alcoholic  beverages. 

After  the  age  of  5  or  6  years  the  diet  may  be  still  further  increased  in 
variety,  being  almost  similar  to  that  suitable  for  adults;  but  care  must 
be  followed,  and  close  supervision  given  up  to  the  age  of  puberty. 

AMOUNT  OF  FOOD-ELEMENTS  AND  NUMBER  OF  CALORIES  REQUIRED 
AFTER  THE  FIRST  YEAR 

A  knowledge  of  the  percentage-composition  and  caloric  value  of  the 
foods  given  after  the  1st  year  is  less  often  required  than  in  infancy,  but 
still  often  very  serviceable.  This  is  particularly  true  when  indigestion 
of  some  form  develops,  or  when  the  question  of  over-feeding  or  under- 
feeding arises.  The  caloric  needs  of  children  after  the  age  of  1  year  have 
not  been  very  extensively  studied.  The  matter  is  reviewed  by  Locke, ^ 
as  also  by  Knox,  ^  based  upon  studies  by  Camerer,^Sommerfeld'*and  others. 
The  total  amounts  of  the  different  ingredients  necessary  vary  decidedly, 
this  depending  in  part  upon  the  fact  that  the  food-elements  are  to  a 
considerable  extent  interchangeable,  but  that  if,  for  instance,  a  larger 
amount  of  fat  is  given  the  total  quantity  of  food  required  is  less,  on 
account  of  the  greater  caloric  value  of  this.  The  average  amounts 
given  by  Sommerfeld,  based  upon  various  collected  analyses  are  shown  in 
the  following  table: 

Table  62. — Daily    Quantity    ov    the    Different    Food-elements    Required 


Age 

Protein,  grams 

Fat,  grams 

Carbohydrates,  grams 

2-4    years 

5-7    years 

8-10  vears 

10-11  vears 

40-64 
50-58 
60-88 
68-86 

32-62 
30-43 
30-70 

44-85 

110-205 
145-197 
220-250 
211-270 

In  round  numbers  he  places  the  needs  as: 

From  2  to  4  years,  protein  50  grams  (1.76  oz.  Av.),  fat  50  grams  (1.76  oz.  Av.) 

carbohydrates  140  grams  (4.94  oz.  Av.). 
From  5  to  8  years,  protein  80  grams  (2.82  oz.  Av.),  fat  65  grams  (2.29  oz.  Av.), 

carbohydrates  220  grams  (7.76  oz.  Av.). 
From  8  to  12years,  protein  85  grams  (3  oz.  Av.),  fat  80  grams  (2.82  oz.  Av.),  carbo- 
hydrates 275  grams  (9.70  oz.  Av.). 

'  Boston  Med.  and  Surg.  Journ.,  1912,  CLXIX,  702. 
«  Journ.  Amer.  Med.  .\.s.soc.,  1916,  LX\II,   i;J2. 

*  Der  StofTwechsel  dcs  Kindes,  ISOC). 

*  Pfaundler  und  Sclilossmann,  llaiidl).  der  Kindcrh.,  190ii,  I,   JOl. 


174 


THE  DISEASES  OF  CHILDREN 


The  actual  amount  of  food  needed  increases  steadily  as  the  child  grows 
older,  but  the  relative  amount  as  compared  with  the  body-weight; 
i.e.  the  energy-quotient,  decreases  steadily.  This  is  dependent  in  part 
upon  the  diminished  ratio  between  the  surface  and  the  body-weight, 
and  in  part  upon  the  relatively  more  rapid  growth  in  the  younger  subjects. 
Taking  the  weight  as  our  guide,  the  caloric  requirements  for  the  1st 
year  have  already  been  detailed  (p.  53).  For  the  age  of  2  years  and  up- 
ward, as  determined  by  Camerer,^  they  may  be  seen  in  the  following  table 
given  by  Sommerfeld.- 


Table  63. — Daily  Total  Amount  of  Food-elements  in  Grams,  and  of  the  Calo- 
ries, PER  Kilogram  of  Body-weight 


Age  in 
years 


Sex 


Total 
food, 
grams 


Water, 
grams 


Protein, 
grams 


Fat, 
grams 


Carbo-         Calories  per 

hydrates,       kilogram  of 

grams         body-weight 


2-4 
5-7 

7-10 

10-14 


Each. 
Girls. 
Bo  vs. 
Girls. 
Boys. 
Girls . 
Boys. 


93.1 

84.4 
84.3 
75.5 
70.8 
54.0 
56.1 


75.3 
67.4 
66.6 
59.0 
55.5 
41.4 
44.4 


3.6 
3.0 
3.5 
2.7 
2.8 
2.1 
2.5 


3.1 
1.9 
2.5 
1.3 
1.3 
1.4 
1.0 


9.2 
10.7 
10.9 

9.9 
10.4 

8.4 

7.7 


75.3 
69.0 
76.6 
59.2 
61.0 
51.4 
47.3 


All  but  the  protein  may  be  varied,  but  this  should  be  approximately  the 
amount  given  in  the  table.  About  30  per  cent,  of  the  food  should  be  of 
animal  origin,  and  about  50  per  cent,  of  the  protein  should  be  of  this 
nature,  the  rest  being  of  vegetable  derivation  (Camerer).  An  examina- 
tion of  the  table  shows  that  the  protein  should  be  from  20  to  25  per  cent, 
of  the  total  diet  excluding  water. 


PERCENTAGE-COMPOSITION  AND  CALORIC  VALUE  OF  VARIOUS  FOODS 
IN  INFANCY  AND  CHILDHOOD 


In  Table  64  may  be  found  the  percentage-composition  and  caloric 
value  of  a  number  of  dietary  articles  likely  to  be  employed  in  infancy  and 
childhood.  They  are  taken,  with  a  few  exceptions  indicated  by  an  asterisk, 
from  the  "Composition  of  American  Food-materials"  by  Atwater  and 
Bryant.^  The  edible  portion  of  the  food  is  that  referred  to  in  nearly  all 
instances,  and  always  unless  otherwise  mentioned,  when  the  letters 
"A.  P."  (as  purchased)  are  appended,  as  by  the  authors.  All  foods 
are  raw  unless  otherwise  stated.  The  equivalents  of  the  caloric  values 
for  kilograms  are  given  in  addition  to  the  avoirdupois  estimations  of 
Atwater  and  Bryant.  The  caloric  values  are  given  in  round  numbers. 
The  percentage-figures  for  human  milk  are  those  very  commonly  adopted, 
and  those  for  top  milk  are  the  approximate  averages  derived  from  a 
number  of  sources,  and  the  caloric  equivalents  for  these  are  calculated  by 
Fraley's  formula  (p.  123).  In  the  measuring  of  milk  and  other  liquids, 
as  expressed  in  ounces,  since  1  pint  of  water  weighs  practically  1  pound 
avoirdupois,  the  difference  between  the  fluid  ounce  and  the  ounce  avoir- 

^  Loc.  cit. 
^Loc.  cit.,  402. 

^  U.  S.  Dept.  Agriculture,  Office  of  Experimental  Station,  Bull.  28,  Revised 
Edit.,  1906. 


FOODS  IN  INFANCY  AND  CHILDHOOD 


175 


dupois  is  slight  enough  to  be  disregarded,  both  as  to  percentage-compo- 
sition and  caloric  value.  A  smaller  list  of  the  caloric  values  of  certain 
foods  as  prepared  for  use  will  be  given  later.     (See  p.  177.) 

Caloric  Value  of  Cooked  Foods. — The  caloric  estimation  of  cooked 
articles  of  diet  can  be  only  approximate,  depending  upon  the  manner  in 
which  the  cooking  is  done.  This  appUes  with  especial  force  to  the  por- 
ridges, since  the  proportions  of  w^ater  and  of  cereal  substance  vary  greatly 
according  to  the  recipe  employed.  Table  65  (p.  177)  is  abstracted  from 
the  long  and  useful  list  given  by  Locke.'  For  further  details  regarding 
the  method  of  preparation  the  reader  is  referred  to  his  book  upon  the 
subject. 


T.\BLE  64. — -Percentage-composition  and  Caloric  EQun''ALENTS  of  Various  Foods 


Food  material 


Water,   Protein, 
per     I       per 
cent,    i     cent. 


Fat, 
per 
cent. 


Carbo- 
hydrate, 
per 
cent. 


Ash, 
per 
cent. 


Cal9ries  per 
avoirdupois 


lb. 


Calories 

per 
kilogram 
or  litre 


Milk  Foods. 
*Human  milk 

Cow's  milk  (average) 

Skimmed  milk;  commercial 

fat-free 

*Top  milk,  32  per  cent.  fat. . 
*Top  milk,  20  per  cent,  fat . . 
*Top  milk,  16  per  cent,  fat . . 
*Top  milk,  12  per  cent.  fat. . 
*Top  milk,  10  per  cent,  fat . . 
*Top  milk,  7  per  cent,  fat . . . 

Buttermilk 

Whey 

Butter 

Meats. 

Beef,  lean  ribs 

Beef,  lean  round 

Beef,  roasted,  A.P 

Beef-steak :  round,  cooked, 
fat  removed,  A.P 

Beef-steak,  loin  broiled .... 

Beef-juice 

Beef-liver 

Mutton,  leg,  lean 

Lamb-chop,  broiled 

Fish,  Halibut 

Fish,  Mackerel 

Bacon,  smoked,  lean 

Fowl 

Capon,  cooked 

Turkey 

Turkey,  roast 


Eggs,  white  boiled 

Eggs,  yolk  boiled 

Sugar  and  Starch. 

Cane-sugar,  granulated 

*Milk-sugar 

Arrowroot 

Cornstarch 


87.0 
87.0 

90.5 


91.0 
93.0 
11.0 

67.9 
70.0 

48.2 

63.0 
54.8 
93.0 
71.2 
67.4 
47.6 
75.4 
73.4 
31.8 
63.7 
59.9 
55.5 
52.0 
73.7 
86.2 
49.5 


2.3 


1.5 
3.3 

3.4 

2.5 

2.9 

3.05 

3.2 

3.3 

3.4 

3.0 

1.0 

1.0 

19.6 
21.3 
22.3 

27.6 
23.5 
4.9 
20.4 
19.8 
21.7 
18.6 
18.7 
15.5 
19.3 
27.0 
21.1 
27.8 
13.4 
12.3 
15.7 


4.0 
4.0 

0.3 

32.0 

20.0 

16.0 

12.0 

10.0 

7.0 

0.5 

0.3 

85.0 

12.0 

7.9 

28.6 

7.7 

20.4 

0.6 

4.5 

12.4 

29.9 

5.2 

7.1 

42.6 

16.3 

11.5 

22.9 

18.4 

10.5 

0.2 

33.3 


7.0 
5.0 

5.1 

3.4 

3.9 

4.2 

4.3 

4.4 

4.45 

4.8 

5.0 


1.7 


100.0 

97!5 
90.0 


0.2  21  330  728 

0.7  20  326  719 

0.7  11  170  I  375 

0.7  87  1398  I  3082 

0.7  59  936  2064 

0.7  48  769  1695 

0.7  ^9  630  1389 

0.7  35  554  1221 

0.7  27  437  963 

0.7  10  165  364 

0.7  8  125  276 

3.0  225  3605  7949 


1.0 
1.1 
1.3 


54 !  870  !  1918 

46 1  730  I  1609 

101  I  1620  ,  3572 


11.0 
1.0 
1.3 
1.0 
1.2 
1.0 
0.6 
1.1 


0.2 


53 
81 
7 
38 
56 

104 
35 
40 

130 
65 
61 
85 
81 
45 
16 

107 


840 

1300 

115 

605 

890 

1665 

565 

645 

2085 

1045 

985 

1360 

1295 

720 

250 

1705 


116  1  I860 
116  18G0 
113  1815 
105  1675 


1852 
2866 

254 
1334 
1962 
3671 
1246 
1422 
4597 
2304 
2172 
2998 
2855 
1587 

551 
3759 

4101 
4101 
4002 
3693 


iFood  Values,  1916. 


176 


THE  DISEASES  OF  CHILDREN 


Table    64. — Percextage-compositiox    and    Caloric    Equivalents    of   Various 

Foods  {Continued) 


Food  material 


Water,    Protein, 
per  per 

cent.    I     cent. 


Fat, 
per 
cent. 


Carbo- 
hydrate, 
per 
cent. 


Calories  per  :  r^^.     • 
Ash.     avoirdupois     Calories 
per 


Oz. 


Lb. 


per 
kilo- 
gram 


Sugar  and  Starch  {Cont'd.). 

Sago 

Tapioca 

Cereals. 

Barley',  pearled 

Barley-flour 

Oat-meal 

Oats,  various  preparations 

Rice 

Wheat,  cracked 

Wheat -flour  (average) .  .  .  . 

Wheat,  whole,  flour , 

Wheat,  farina 

Wheat,  macaroni 

T\Tieat-bread,  average .  . .  . 

Whole  wheat-bread 

Bread,  Graham 

WTieat-bread,  toast 

Zwieback 

Rolls  (average) 

Corn-meal 

Corn-bread 

Corn-homin!y 

Crackers,  various  average. 
Vegetables. 

Asparagus,  A.P 

Beans,  Lima 

Beans,  string 

Beets 

Carrots 

Celery 

Lettuce 

Onions 

Peas 

Potatoes 

Potatoes,  sweet 

Spinach 

Squash 

Fruits. 

Apples 

Blackberries .■ 

Dates,  pressed 

Figs,  pressed 

Grapes 

Oranges 

Peaches 

Pears 

Prunes,  dried 

Raspberries,  red 


12.2 
11.4 

11.5 
11.9 

7.3 

7.9 
12.3 
10.1 
12.0 
11.4 
10.9 
10.3 
35.3 
38.4 
35.7 
24.0 

5.8 
29.2 
11.6 
38.9 
11.8 

6.8 

94.0 
68.5 
89.2 
87.5 
88.2 
94.5 
94.7 
87.6 
74.6 
78.3 
69.0 
92.3 
88.3 

84.6 
86.3 
15.4 
18.8 
77.4 
86.9 
89.4 
84.4 
22.3 
85.8 


9.0 
0.4 

8.5 

10.5 

16.1 

16.3 

8.0 

11.1 

11.4 

13.8 

11.0 

13.4 

9.2 

9.7 

8.9 

11.5 

9.8 

8.9 

8.4 

7.9 

8.3 

10.7 

1.8 

7.1 

2.3 

1.6 

1.1 

1.11 

1.2 

1.6 

7.0 

2.2 

1.8 

2.1 

1,4 

0.4 
1.3 
2.1 
4.3 
1.3 
0.8 
0.7 
0.6 
2.1 
1.0 


0.4 
0.1 

1.1 
2.2 
7.2 
7.3 
0.3 
1.7 
1.0 
1.9 
1.4 
0.9 
1.3 
0.9 
1.8 
1.6 
9.9 
4.1 
4.7 
4.7 
0.6 
8.8 

0.2 
0.7 
0.3 
0.1 
0.4 
0.1 
0.3 
0.3 
0.5 
0.1 
0.7 
0.3 
0.5 

0.5 
1.0 
2.8 
0.3 
1.6 
0.2 
0.1 
0.5 


78.1 
88.0 

77.8 
72.8 
67.5 
66.8 
79.0 
75.5 
75.1 
71.9 
76.3 
74.1 
53.1 
49.7 
52.1 
61.2 
73.5 
56.7 
74.0 
46.3 
79.0 
71.9 

3.3 
22.0 

7.4 

9.7 

9.3 

3.3 

2.9 

9.9 

16.9 

18.4 

27.4 

3.2 

9.0 

14.2 
10.9 
78.4 
74.2 
19.2 
11.6 
9.4 
14.1 
73.3 
12.6 


0.3  102 
0.1  103 


0.1 


103 


2.6  103 
1.9i  116 
1.7j  116 
0.4  102 
1.6  105 


0.5 
0.9 
0.4 
1.3 
1.1 
1.3 
1.5 
1.7 
1.0 
1.1 
1.3 
2.2 
0.3 
1.8 

0.7 
1.7 
0.8 
1.1 
1.0 
1.0 
0.9 
0.6 
1.0 
1.0 
1.1 
2.1 
0.8 

0.3 
0.5 
1.3 
2.4 
0.5 
0.5 
0.4l 
0.41 
2.3! 
0.6' 


103 

105 

105 

104 

76 

71 

76 

89 

123 

87 

108 

75 

103 

119 

7 
36 
12 
13 
13 

5 

6 
14 
29 
24 
36 

7 
13 

18 
17 
101 
92 
28 
15 
12 
18 
88 
16 


1635 
1650 

1650 
1640 
1860 
1855 
1630 
1685 
1650 
1675 
1685 
1665 
1215 
1140 
1210 
1420 
1970 
1395 
1730 
1205 
1650 
1905 

105 
570 
195 
215 
210 
85 
90 
225 
465 
385 
570 
110 
215 

290 

270 

1615 

1475 

450 

240 

190 

295 

1400 

255 


3605 
3638 

3638 
3616 
4101 
4090 
3594 
3715 
3638 
3693 
3715 
3671 
2679 
2513 
2668 
3131 
4343 
3075 
3814 
2657 
3638 
4200 

231 

1257 

430 

474 

463 

187 

198 

496 

1025 

848 

1257 

243 

474 

639 

595 

3561 

3252 

992 

529 

419 

650 

3087 

562 


FOODS  IN  INFANCY  AND  CHILDHOOD  177 

Table  65. — Caloric  Value  of  Definite  Portions  of  Foods  Prepared  for  Use 


Foodstuffs 


Quantity- 


Weight, 
gramB 


Total 
calories 


Meats. 

Beef-juice 

Beef,  roast 

Beef,  roast  (lean) 

Steak,  tenderloin 

Chicken,  roast 

Lamb  chop  (with  bone) 

Mutton,  roast 

Mackerel,  boiled 

Halibut,  boiled 

Soups. 

Cream  (various  sorts) .  . 

Consomme 

Bouillon 

Beef -soup 

Bean-soup 

Chicken-soup 

Vegetables. 

Beans,  string 

Beans,  lima 

Beans,  baked  (home) . . . 

Beets 

Carrots 

Celery,  creamed 

Peas,  green 

Potato,  baked 

Potato,  mashed 

Spinach 

Cereals. 

Bread,  white  (home) 1 

Bread,  white  (baker's) 1 

Bread,  whole  wheat 1 

Bread,  toasted \}4 

Zwieback 1 

Farina 

Hominy,  boiled. 

Oatmeal,  boiled. 

Rice,  boiled 

Macaroni,  boiled 

Corn-meal  mush . 
Miscellaneous. 

Eggs,  boiled 

Omelette 

Apple,  baked .... 

Apple-sauce 

Prunes,  stewed .  . 

Cocoa 


4  oz. 


slice 
slice 
slice 
sUce 


1  slice 


fl.  oz. 
fi.  oz. 
fl.  oz. 
fl.  oz. 
fl.  oz. 
fl.  oz. 


/■■ 


2  hp.  tbsp. 

2  hp.  tbsp. 

3  hp. tbsp. 

2  hp. tbsp. 

3  hp.  tbsp. 
3  hp.  tbsp. 
3  hp.  tbsp. 
med.  size 
2  hp.  tbsp. 
2  hp.  tbsp. 

slice  (3X4Xj^) 
slice  (33^X3XH) 
slice  (3^X31^  XM) 
slice  {4X2XH) 
slice  (31^X2X3^) 

2  hp.  tbsp. 

2  hp. tbsp. 

2  hp.  tbsp. 

1  hp.  tbsp. 

2  hp.  tbsp. 

3  hp.  tbsp. 


1  large 
3  hp.  tbsp. 
4  large,  with  juice 
1  cup 


120 
100 
100 
100 
100 
100 
75 
70 
100 

125 
120 
120 
120 
120 
120 

60 

80 

150 

70 

100 

90 

92 

130 

100 

100 

37 
30 

42 
10 
15 
100 
100 
100 
100 
100 
115 


31 
357 
111 
286 
181 
367 
234 
104 
121 

70-162 
14 
13 
32 

78 

72 

13 
128 
298 

29 

18 

66 
110 
149 
112 

57 

100 

80 
106 

31 

65 

56 

84 

63 
112 

91 

96 


50 

83 

75 

177 

120 

128 

125 

201 

200 

189 

227 

279 

12 


CHAPTER  VIII 
DIET  IN  SICKNESS 

Only  general  rules  can  be  given  here,  in  addition  to,  or  by  way  of 
summary  of,  what  has  been  said  in  various  places  under  the  different 
headings  of  infant-feeding,  and  of  what  will  be  included  in  the  study  of 
the  individual  diseases. 

In  the  case  of  breast-fed  infants  under  1  year,  the  development  of 
acute  gastric  disturbance  often  renders  it  advisable  to  stop  nursing 
entirely  for  12  or  more  hours,  giving  barley-water  or  other  cereal  decoction 
in  its  place.  The  mother's  milk  may  be  examined  and,  if  faulty,  modified 
if  possible.  The  withdrawal  of  the  breast  may  continue  for  a  few  days 
if  necessary,  but  be  made  permanent  only  if  symptoms  of  indigestion 
are  persistent  or  repeated  and  the  infant  ceases  to  thrive  in  other  respects., 
Mixed  feedings  should  be  tried  before  weaning  the  child  completely. 

In  the  case  of  bottle-fed  infants  acutely  ill  with  some  digestive  dis- 
turbance, a  general  rule  which  can  be  wisely  followed  in  most  instances 
is  to  administer' a  purgative  and  to  stop  the  milk-mixture  entirely  for  at 
least  24  hours,  giving  a  weak  cereal  decoction,  such  as  barley-water,  in 
its  place.  After  this  a  graduated  but  fairly  rapid  return  to  the  former 
food  may  be  made.  It  is  a  mistake  to  institute  any  permanent  radical 
change  in  a  diet  which  has  previously  agreed  well.  Should,  however,  the 
digestive  disturbance  constantly  recur,  and  the  infant  cease  to  do  well 
in  other  respects,  being  a  case  of  "feeble  digestion,"  a  very  decided  alter- 
ation of  the  diet  or  of  other  factors  connected  with  it  should  be  made 
promptly,  since  the  longer  the  disturbance  continues,  the  greater  the  effect 
upon  the  infant,  and  the  harder  it  is  to  restore  it  to  a  condition  of  health. 

What  change  shall  be  made  can  be  determined  only  by  a  careful  study 
of  the  individual  case.  When  persistent  vomiting  is  the  symptom  present, 
it  is  oftenest  the  fat  which  is  at  fault,  and  the  percentage  of  this  must  be 
reduced  very  greatly.  Food  in  which  skimmed-milk  is  the  basis  is 
frequently  very  useful  in  this  condition.  If  reduction  of  the  fat  does  not 
succeed,  the  sugar  should  be  suspected.  Sometimes  the  employment  of 
lactose  instead  of  maltose  or  saccharose  is  efficacious;  sometimes,  contrary 
to  what  is  to  be  expected,  the  reverse  is  the  case;  sometimes  no  sugar  is  well 
borne.  Buttermilk  has  the  advantage  that  it  is  low  both  in  fat  and  sugar, 
and  is  sometimes  very  serviceable.  Even  when  fortified  with  wlieat-flour 
and  cane-sugar,  it  is  still  of  value  in  many  cases  of  vomiting,  provided 
this  is  not  dependent  upon  a  sugar-intolerance.  In  this  connection 
we  must  not  forget  that  it  is  not  alone  the  nature  of  the  nourishment 
but  other  factors  which  may  cause  and  maintain  vomiting.  Often  the 
food  is  given  in  too  large  an  amount,  too  frequently,  or  too  rapidly. 
Whether  it  is  better  to  give  a  large  quantity  of  a  diluted  food  or  a  smaller 
amount  of  a  more  concentrated  nourishment  is  a  question  to  be  settled 
often  only  by  trial.  Certainly  the  intervals  of  feeding  should  as  a 
rule  be  lengthened,  and  the  possible  existence  of  other  forms  of  faulty 
management  sought  for.  (See  Action  of  Milk-elements,  p.  127  and 
Vomiting,  p.  700.) 

178 


DIET  IN  SICKNESS  179 

When  diarrhea  is  the  prominent  symptom,  again  the  fat  is  first  to  be 
suspected,  especially  if  the  stools  contain  large  numbers  of  soft,  white 
curds;  or  the  sugar  if  the  stools  are  green  or  yellow-green  and  have  a  sour 
odor.  Should  the  infant  be  thriving,  the  condition  not  acute,  and  the 
stools  not  very  frequent  in  number,  no  immediate  change  need  neces- 
sarily be  made,  but  the  condition  carefully  watched.  Diarrheal  stools 
if  of  a  foaming  character  with  irritation  of  the  buttocks  depend  upon  an 
excess  of  sugar.  As  lactose  and  dextrin-maltose,  if  in  large  amount,  are 
liable  to  produce  this  disturbance,  saccharose  may  be  substituted;  but 
it  is  better  to  begin  with  no  addition  of  sugar,  and  to  make  this  very 
gradual.  The  employment  of  malt-soup,  modified  in  ways  to  diminish 
the  amount  of  converted  starch  present,  gives  good  results  in  some 
instances,  but  in  others  increases  the  diarrhea.  Buttermilk-mixture 
(p.  148)  is  also  useful  in  many  instances,  and  in  others  casein  milk  (p.  148) ; 
both  having  a  low  percentage  of  lactose,  and  a  high  percentage  of  casein, 
the  latter  a  moderate  amount  of  fat  and  the  former  replacing  this  by 
a  high  carbohydrate-addition  in  the  form  of  saccharose,  which  may  be 
tolerated  when  lactose  is  not.  The  casein-milk,  at  first  without  sugar 
addition,  is  to  be  selected  when  it  is  thought  that  the  sugar  disagrees;  the 
other  when  the  fat  is  especially  suspected. 

Constipation  may  call  for  a  modification  of  the  diet.  (See  also  p.  757.) 
Apart  from  other  causes  it  may  depend  upon  too  small  an  amount  of  food 
ingested  as  a  whole,  or  of  one  of  the  elements,  usually  fat  or  carbohydrate. 
Constipated,  thriving  children  may  have  such  complete  absorption  from 
the  intestine  that  little  waste  remains.  When  the  stools  are  dry  and  fight 
colored  and  perhaps  offensive,  there  is  generally  an  excess  of  fat  and  some- 
times of  protein  or  a  lack  of  sufficient  carbohydrate.  The  increase  of 
the  latter  will  often  change  the  character  of  the  stools  and  relieve  consti- 
pation, and  especially  so  if  a  combination  of  starch  with  a  dextrin-mal- 
tose preparation  be  employed,  as  exists  in  malt-soup. 

The  significance  of  colic  is  very  uncertain.  Sometimes  it  depends  in 
no  way  upon  the  character  of  the  food,  and  it  is  a  common  attendant 
upon  constipation.  When  the  food  is  without  doubt  the  cause,  the 
exact  method  of  production  of  the  colic  is  still  frequently  uncertain. 
An  excessive  carbohydrate-intake,  especially  of  starch,  is  often  a  factor, 
as  is  also  sometimes  too  high  a  percentage  of  protein.  This  protein  indi- 
gestion occurs  in  probably  but  a  relatively  small  number  of  cases.  The 
symptoms  are  indefinite  and  not  entirely  understood,  the  most  suggestive 
in  addition  to  the  colic  being  the  occurrence  of  offensive  stools  with  a 
putrefactive  odor,  either  diarrheal  or  constipated,  and  sometimes  of 
hard,  yellow-white  protein  curds  in  the  passages  if  the  milk  has  been 
given  raw.  In  the  way  of  dietetic  modification,  the  casein  may  be  reduced 
l)y  the  employment  of  whej'-mixtures  with  cream,  or  the  milk  may  be 
boiled  or  be  peptonized.     (See  also  Colic,  p.  728.) 

The  employment  of  thin  cereal  waters  in  the  case  of  sick  children  has 
already  been  referred  to.  In  some  instances,  especially  in  infants  past 
the  age  of  6  months,  benefit  in  digestive  disorders  is  obtained  by  giving 
a  stronger  cereal-food,  entirely  without  milk  at  first.  This  is  sometimes 
digested  much  better  than  either  fat  or  sugar.  Small  and  gradually 
increasing  amounts  of  milk  should  be  added  as  soon  as  possible,  inasmuch 
as  the  diet  is  generally  too  insufficient  in  protein  for  employment  for  any 
considerable  time.  One  of  the  most  trying  evitiences  of  malassimila- 
tion  of  the  food  is  that  in  which,  without  sufficient  vomiting  or  diarrhea 
to  account  for  it,  there  is  a  persistent  failure  to  gain  weight,  or  even  a  loss 


180  THE  DISEASES  OF  CHILDREN 

of  it.  This  may  depend  upon  an  insufficient  amount  of  nourishment, 
but  oftener  is  the  final  result  of  the  giving  of  food  which  was  too  strong, 
especially  in  fat.  The  employment  of  a  high  carbohydrate-diet  with 
a  low  fat-percentage  is  at  times  one  of  the  best  remedies.  Where  a 
mere  insufficient  amount  of  food  offered  is  the  cause,  the  condition  is 
readily  curable.  In  other  instances  the  appetite  is  very  poor,  and  food 
is  refused.  Here  good  may  come  from  lengthening  the  feeding-intervals. 
The  feeding  of  these  cases  of  disturbed  digestion  will  be  studied  more  in 
detail  in  considering  the  diseased  conditions  in  which  the  symptoms  occur. 

In  children  over  1  year  of  age  the  presence  of  persistent  weakness 
of  digestion  may  necessitate  the  continuance  of  the  use  of  milk  in  modifi- 
cations which  would  suit  younger  normal  infants.  In  other  cases  the 
best  course  is  to  eliminate  milk  more  or  less  completely  for  a  time.  The 
giving  of  beef-juice  and  of  scraped  underdone  meat  is  often  useful  under 
such  conditions,  while  the  effects  of  fat  and  of  carbohydrate,  especially 
starch,  must  be  watched  carefully.  Each  case  is  a  rule  to  itself,  and  the 
diet  must  be  studied  and  altered  as  with  infants  under  1  year.  Particu- 
larly about  the  age  of  2  years  or  later  there  is  liable  to  develop  a  form 
of  chronic  indigestion  which  depends  upon  too  free  a  use  of  amylaceous 
food.  This  starchy  indigestion  requires  a  modification  of  the  diet  by 
which  milk  and  meat,  and,  to  some  extent,  green  vegetables  constitute 
the  principal  articles  of  food,  and  starch  is  reduced  to  a  minimum.  In 
my  own  experience  an  excess  of  protein  in  the  diet  after  the  2d  year  is 
less  often  harmful  than  is  an  excess  of  carbohydrate. 

In  many  of  the  febrile  diseases  in  infants  or  older  children,  vomiting 
is  the  first  symptom.  When  this  is  active,  little  or  no  effort  should  be 
made  to  give  nourishment.  So,  too,  the  disHke  for  food  often  seen  in 
acute  febrile  disorders  need  be  no  cause  of  alarm.  It  is  a  natural  result 
of  the  impaired  digestive  power  always  present,  and  nourishment  should 
not  be  urged.  If  the  attack,  however,  is  prolonged,  or  when  the  condi- 
tion is  such  that  inanition  is  threatening  from  lack  of  food,  the  physician 
must  feed  sufficiently,  although  cautiously.  It  may  even  be  necessary 
to  employ  gavage.  Curiously,  in  some  cases  of  obstinate  vomiting  in 
infants,  food  given  by  gavage,  immediately  following  lavage,  will  be  re- 
tained when  swallowed  nourishment  is  not.  (See  Gavage,  p.  247.)  It 
is  seldom  that  a  sick  child  may  not  have  water  as  often  and  as  much  as 
it  desires.  It  is  chiefly  when  the  administration  of  water  appears  to 
excite  vomiting  that  the  amount  given  must  be  restricted.  Thirst  is  very 
intense  in  the  febrile  disorders,  and  it  has  been  the  misguided  practice  of 
many  of  the  laity  to  limit  the  amount  of  water.  This  is  both  dangerous 
and  cruel.  The  water  should  be  cool,  but  not  cold.  Sometimes,  for 
older  children,  a  carbonated  water  is  to  be  preferred.  Nursing  infants 
with  fever  should  have  water  given  from  a  spoon,  since,  if  allowed  to 
quench  their  thirst  by  nursing,  they  may  readily  over-feed  themselves. 
On  the  other  hand,  it  sometimes  happens,  where  the  giving  of  nourish- 
ment is  important,  that  the  existence  of  thirst  may  be  taken  advantage  of 
in  older  children,  since,  in  order  to  quench  it,  the  child  may  be  induced  to 
drink  cool  milk  if  water  is  withheld ;  or  water  may  be  given  as  a  reward 
after  the  milk  is  taken. 

Great  regularity  should  exist  in  the  feeding  of  sick  children.  Liquid 
nourishment  should  be  given  every  3  hours,  or  sometimes  every  1  or  2 
hours  or  oftener  when  very  little  is  taken  at  a  time;  but  as  a  rule  the  in- 
terval should  be  long.  The  impairment  of  the  digestive  power  present 
in  the  acute  febrile  disorders,  not  themselves  of  digestive  origin,  often 


DIET  IN  SICKNESS  181 

makes  it  advisable  that  the  food  be  weaker  than  that  used  in  health,  and 
especially  that  the  fat  be  reduced.  Infants  who  have  been  receiving  a 
modified  milk  mixture  should  have  this  weakened,  and  children  who  have 
been  on  soKd  food  require  a  Hquid  diet.  Of  all  forms  of  hquid  diet  for 
older  children  that  oftenest  serviceable  is  milk,  which  should  be  diluted 
and  may  often  be  alkahnized  with  hme-water  with  advantage.  In  the 
cases  where  milk  is  disagreeable  to  or  disagrees  with  the  child  we  may 
fall  back  upon  such  foods  as  egg-water  or  raw  egg  given  in  other  ways, 
beef-juice,  commercial  peptonized  beef-preparations,  and  broths  thickened 
with  starchy  food.  Clear  broths,  though  appetizing,  have  little  nutritive 
power.  JelUes  do  not  nourish  to  any  extent,  but  well-made  ice-cream  is 
often  a  valuable  food  in  selected  cases  for  children  who  have  lost  appetite 
and  need  feeding.  It  should  be  given,  however,  rather  as  a  reward,  and 
not  made  a  constant  article  of  diet,  as  its  sweetness  is  liable  to  cause  or 
increase  indigestion. 

In  long-continued  illnesses  often  one  of  the  greatest  problems  is  to 
maintain  the  state  of  the  general  nutrition  in  a  satisfactory  manner.  In 
giving,  then,  the  restricted  diet  referred  to,  the  greatest  caution  must  be 
exercised  not  to  overdo  the  matter.  I  have  repeatedly  seen  children 
whose  chief  ailment  after  some  illness  was  that  they  had  been,  and  still 
were,  greatly  underfed.  In  cases  of  obstinate  vomiting  food  may  some- 
times be  given  in  the  form  of  nutrient  suppositories,  or,  oftener,  of  nutri- 
ent enemata.  These,  however,  do  not  fill  the  place  which  they  do  in  adult 
life,  owing  to  the  difficulty,  especially  in  infancy,  of  having  them  retained 
and  the  deficient  absorption  which  occurs.  As  a  rule,  they  are  unsatis- 
factory at  this  period  of  life. 


CHAPTER  IX 
CHARACTERISTICS  OF  DISEASE  IN  INFANCY  AND  CHILDHOOD 

The  diseases  of  early  life  vary  decidedly  from  those  occurring  later. 
Not  only  are  the  causes  often  different,  but  the  reaction  of  the  growing 
tissues  in  earty  j^ears  is  not  the  same  as  in  adult  Ufe.  Anatomical  and 
physiological  distinctions  also  exist.  There  is  consequently  seen  a  tend- 
ency to  the  development  of  certain  diseases  in  infancy  and  childhood, 
and  an  immunity  toward  others.  Certain  maladies  are  peculiar  to  early 
Hfe;  others  exhibit  chnical  manifestations  characteristic  of  that  period. 
The  susceptibility  of  the  incompletely  developed  nervous  system  is  very 
great,  often  masking  the  real  nature  of  the  disorder.  Trifling  factors 
thus  produce  general  symptoms  which  are,  or  appear  to  be,  severe  out. 
of  all  proportion  to  their  causes,  similar  agencies  acting  in  adults  giving 
rise  to  no  symptoms  of  moment.  The  initial  effect  of  deleterious  influ- 
ences is  often  unusually  marked  in  early  life,  and  the  development  of 
symptoms  very  rapid  and  apparently  severe;  while,  on  the  other  hand, 
the  recuperative  power  is  great,  and  convalescence  is  speedy.  Various 
causes  render  the  examination  of  a  sick  child  difficult.  There  are  also 
marked  peculiarities  at  this  period  in  the  reaction  of  the  system  to  cer- 
tain drugs,  some  of  the  materia  medica  being  unusually  well  tolerated, 
and  others  not  at  all  so. 

After  early  childhood  is  passed,  and  particularly  after  the  age  of  7  or 
8  years,  the  pecuUarities  attending  the  study  of  disease  are  less  marked. 

ETIOLOGY 

Among  the  causes  predisposing  to  the  development  of  certain  dis- 
orders in  children  direct  or  indirect  inheritance  plays  an  important  role. 
Syphilis  in  either  parent  is  directly  inherited,  as  probably  are  very  occa- 
sionally such  of  the  acute  infectious  diseases  as  typhoid  fever,  scarlatina, 
variola  and  some  others.  Tuberculosis  existing  in  the  parents  certainly 
predisposes  to  its  development  in  the  offspring,  as  do  various  nervous 
disorders,  such  as  epilepsy,  insanity,  the  neuropathic  diathesis,  and  some 
of  the  muscular  dystrophies.  Rheumatism  and  gout  are  also  to  be 
named.  Some  of  these  diseases  may  not  actually  show  themselves  until 
childhood  is  past,  although  the  seeds  of  them  are  present  in  the  system. 

To  be  mentioned  also  is  the  etiological  influence  upon  the  diseases  of 
the  infant  of  the  various  morbid  conditions  incident  to  fetal  life  and  to 
birth,  which  will  be  referred  to  again  (p.  209).  Maternal  impressions  have 
frequently  been  considered  a  powerful  factor  in  the  production  of  some 
of  these;  but  although  much  evidence  has  been  adduced  in  favor  of  this 
view,  the  element  of  coincidence  is  too  often  ignored,  and  positive  proof 
of  any  casual  relationship  is  entirely  unsatisfactory. 

Imperfect  feeding  and  hygiene  are  among  the  most  active  causes  of 
disease  in  infancy  and  childhood.  As  a  result  arise  the  many  forms  of 
disturbed  digestion  and  their  consequences;  such  constitutional  conditions 

182 


GENERAL  METHODS  OF  EXAMINATION  AND  DIAGNOSIS       183 

as  rickets  and  scurvy;  the  disordered  states  of  the  respiratory  apparatus  so 
common  in  children,  and  the  diseases  which  depend  upon  lack  of  proper 
care  of  the  nervous  system.  The  influence  of  school  life  is  responsible 
for  many  nervous  ailments,  affections  of  the  eyes,  deformity  of  the 
spine,  and  disorders  of  the  general  health. 

Infection,  finally,  has  unusual  etiological  power  in  children,  the  great 
majority  of  cases  of  acute  infectious  diseases  being  witnessed  at  this 
period.  This  is  partly  due  to  a  greater  degree  of  susceptibility;  partly 
to  a  much  greater  opportunity  of  exposure;  and  partly  to  the  fact  that 
most  adults  have  already  become  immune  through  earUer  occurrence  of 
these  affections. 

GENERAL  METHODS  OF  EXAMINATION  AND  DIAGNOSIS 

There  are  a  few  respects  in  which  the  study  of  disease  in  infancy  and 
childhood  is  easier  than  in  adult  life.  Existence  having  been  of  shorter 
duration,  there  is  generally  a  shorter  history  to  be  obtained.  There  are 
fewer  compHcating  diseases,  at  least  in  the  acute  affections,  and  there 
are  fewer  previous  varied  bad  habits  of  hving  to  be  taken  into  account. 

On  the  whole,  however,  the  subject  presents  many  and  varied  dif- 
ficulties. Many  affections  exhibit  in  childhood  sjniiptoms  different  from 
those  of  adult  life,  and  the  significance  of  even  the  same  symptom  often 
differs;  while  there  are  also  many  diseases  which  are  almost  or  entirely 
pecuUar  to  early  fife.  Again,  the  infant  cannot,  without  speech,  describe 
its  symptoms,  and  the  older  child  cannot  be  trusted  to  give  an 
accurate  account.  The  inability  to  control  the  patient  presents  another 
difficulty,  and  the  constant  crying  of  an  infant  may  render  a  satisfactory 
examination  impossible.  Considerable  skill,  patience  and  tact  are 
therefore  required. 

Obtaining  the  History. — As  a  sequence  to  what  has  been  said, 
dependence  must  be  placed  on  the  gathering  of  a  careful  and  complete 
cUnical  history  from  the  mother  or  nurse.  In  infancy  there  is,  of  course, 
no  history  obtainable  from  the  patient,  and  even  up  to  the  age  of  6  or  7 
years,  the  child  either  refuses  to  answer  questions  on  account  of  timidity, 
or  makes  repHes  which  are  not  dependable.  The  presence  of  pain,  for 
instance,  may  be  denied  when  it  really  exists,  or  maintained  when  not 
existing,  and  the  localization  by  the  patient  is  very  misleading,  pain 
in  the  chest  being  perhaps  referred  to  the  throat  or  abdomen,  and  so  on. 
There  should  be  some  definite  order  followed  in  the  procuring  of  the 
history  from  the  attendant.  Considerable  latitude  is,  of  course,  allowable, 
dependent  upon  the  nature  of  the  ailment;  yet,  in  general,  the  first  point 
should  be  a  brief  statement  of  the  present  complaint  limited  to  a  very 
few  words;  next,  the  past  cHnical  history  of  the  patient;  third,  the  de- 
tailed account  of  the  present  illness,  and,  last,  the  family  history.  To 
reverse  this  order  renders  the  asking  of  numerous  useless  questions 
unavoidable. 

After  eliciting  vcr>'  briefly  the  chief  symptoms  from  which  the  child 
seems  to  be  suffering,  it  is  often  well  to  allow  the  mother  to  give  as  full 
an  account  as  possible  of  the  case,  in  her  own  wa}'  and  undisturbed  by 
interruptions,  unless  these  become  necessary.  Ordinarily  the  history  may 
best  be  heard  in  the  presence  of  the  chilcl,  who,  meanwhile,  is  growing 
accustomed  to  the  plij^sician's  presence,  ant!  who,  unknown  to  itself, 
is  at  the  same  time  under  the  quiet  observation  of  the  physician's  eye. 
If  the  mother's  mind  is  distracted  by  the  child's  crying,  or  if  the  child 


184  THE  DISEASES  OF  CHILDREN 

is  a  nervous  one  who  may  be  injuriously  affected  by  hearing  the  question- 
ing, the  histor}^  should  be  obtained  in  another  room.  While,  as  a  rule, 
the  mother's  opinions  are  of  httle  value,  her  statements  of  what  she  has 
noticed  must  be  hstened  to  and  weighed  with  care;  since  by  her  constant 
association  with  the  child,  and  by  her  natural  anxiety,  her  powers  of 
observation  have  sometimes  become  very  keen,  and  she  is  rendered 
peculiarly  able  to  detect  even  slight  changes  from  the  ordinary  condition 
of  health.  After  the  mother  has  finished  her  account,  she  should  be 
subjected  to  careful  questioning*  by  the  physician,  much,  or  all,  of  the 
child's  life  being  passed  in  review.  Leading  questions  must  be  avoided 
as  much  as  possible,  for  the  suggestions  which  these  offer  are  very  liable 
to  lead  to  erroneous  statements. 

Previous  History. — In  the  case  of  infants  this  should  date  from  birth ; 
and  this  applies  with  equal  truth  to  many  older  subjects.  Among  the 
data  concerning  which  information  will  be  sought  are  the  existence  of 
prematurity,  of  asphyxia  following  birth,  the  nature  of  the  labor,  the 
process  of  dentition,  the  time  when  sitting  and  walking  were  begun, 
the  birth-weight  and  the  subsequent  alterations,  the  frequency  of  micturi- 
tion, the  freedom  of  perspiration,  the  character  of  the  sleep,  the  existence 
of  mouth-breathing,  the  state  of  the  bowels,  the  condition  of  general' 
nutrition  and  the  time  when  any  change  in  this  was  seen,  the  condition 
of  the  nervous  symptoms  in  general,  and  the  psychic  development, 
often  best  shown  by  the  degree  of  interest  taken  and  the  ability  to  under- 
stand and  to  talk.  Particular  attention  must  be  paid  to  the  minutest 
details  of  the  different  methods  of  feeding  which  have  been  employed 
and  to  the  effects  of  these;  whether  weaning  has  taken  place,  and,  if  so, 
why.  The  statement,  for  instance,  that  the  baby  had  been  fed  on 
modified  milk  is  not  sufficient.  The  proportions  of  milk,  water  and  the 
like  should  be  ascertained.  Especial  care  must  be  given,  too,  to  dis- 
covering the  date,  nature,  mode  of  onset  and  duration  of  all  previous 
illnesses.  This  is  often  a  matter  of  some  difficulty,  and  may  require 
careful,  patient  questioning. 

Present  Illness. — We  can  next  take  up  the  illness  from  which  the  child 
is  now  suffering.  The  exact  date  of  onset  and  the  sequence  of  the 
symptoms  is  a  matter  of  importance,  and  maj"  require  time  and  skill  to 
elicit.  At  least  the  mother  is  generally  able  to  say  at  what  time  she 
considered  the  child  to  have  been  entirely  well.  A  detailed  description  of 
the  symptoms  which  have  been  observed  is  to  be  sought  for.  The  nature 
of  the  questions  varies,  of  course,  with  the  case.  The  degree  and  per- 
sistence of  fever  is  important,  although  the  history  in  this  respect  is  of 
little  value  unless  the  thermometer  has  been  used.  Interrogations  should 
be  made  regarding  the  state  of  the  general  nervous  system,  as,  for  in- 
stance, the  occurrence  of  restlessness,  crying,  sleeplessness,  drowsiness, 
coughing,  twitching,  and  the  existence  of  pain;  the  degree  of  apparent 
exhaustion  or  prostration  determined  by  the  previous  desire  of  the  patient 
to  be  in  bed  or  out,  and  the  presence  or  absence  of  a  desire  to  play  with 
toys;  the  position  in  bed;  and  the  like.  In  digestive  disorders  the  history 
should  be  obtained  of  the  mode  of  onset  and  the  nature  of  the  food  at 
the  time,  the  history  of  vomiting  or  diarrhea  and  the  number  of  daily 
occurrences  of  these,  the  character  of  the  vomitus  or  the  stools,  and  the 
state  of  the  appetite. 

Family  History. — The  nature  of  the  questions  asked  will  naturally 
depend  upon  what  has  already  been  learned.  They  should  include  the 
clinical  history  of  other  children  of  the  family,  the  parents,  and  often 


GENERAL  METHODS  OF  EXAMINATION  AND  DIAGNOSIS       185 

of  the  grandparents  and  other  direct  or  indirect  antecedents  when  the 
existence  of  a  possible  inheritance  is  involved.  Among  the  matters 
which  need  to  be  investigated  are  the  general  health  of  the  family  and 
antecedents,  the  occurrence  in  them  of  tuberculosis,  nervous  disorders, 
rheumatism,  gout,  insanity,  alcohohsm,  the  number  of  children  living 
or  dead,  and  the  causes  of  death.  The  existence  of  parental  syphilis 
must  usually  be  approached  with  caution.  In  place  of  direct  questions 
information  may  be  gained,  for  instance,  regarding  the  occurrence  of 
numerous  miscarriages,  the  history  of  maternal  cutaneous  eruptions,  and 
the  like. 

Method  of  Examining  the  Child. — Now  follows  the  direct  examina- 
tion of  the  child — an  examination  which,  as  stated,  has  been  all  this  while 
quietly  going  on  to  a  certain  extent.  Very  young  infants  take  no  notice 
of  the  physician's  presence.  Older  children,  however,  often  have  much 
fear  of  strangers,  and  perhaps,  from  previous  experience  or  suggestion, 
especially  of  physicians.  A  quick  glance  at  the  patient  on  entering  the 
room,  or  the  manner  in  which  a  word  of  cheery  greeting  is  received,  win- 
often  reveal  something  of  the  peculiarities  of  the  child  in  this  respect. 
It  is  often  a  good  plan  to  seem  to  ignore  absolutely  even  the  existence 
of  a  somewhat  timid  or  irritable  child.  It  quite  frequently  happens  that 
the  confidence  which  this  inspires,  as  well  as  a  certain  degree  of  pique 
which  it  occasions,  will  soon  cause  the  child  itself  to  make  advances 
toward  a  further  acquaintance;  whereupon  a  skilful  response  to  its  over- 
tures will  soon  estabhsh  the  most  friendly  relations  between  doctor  and 
patient.  Avoidance  of  all  hurry,  and  the  use  of  gentle  words  and  actions, 
often  aid  in  rendering  a  child  willing  to  submit  quietly  to  an  examination. 
Sometimes  this  can  be  made  to  appear  a  game  which  the  physician  is 
playing  with  his  little  patient. 

In  the  case  of  many  children  whose  timidity  seems  too  great  to  be 
overcome,  and  especially  with  those  who  have  been  spoiled  by  indulgent 
parents,  and  who  seem  to  resent  in  an  ugly  spirit  the  physician's  pres- 
ence, nothing  whatever  is  gained  by  delay,  and  it  is  best  to  proceed 
quietly,  gently,  yet  firmly  with  the  examination,  regardless  of  any 
objections  made.  Many  such  children,  observing  that  the  physician 
goes  on  with  his  work  in  spite  of  protest,  learn  the  uselessness  of  this 
and  behave  better  at  future  visits.  Very  often  the  difficulty  is  with  the 
mother  rather  than  with  the  child. 

A  sincere  love  for  children,  a  quick  recognition  of  a  child's  peculiarities 
of  disposition,  a  ready  adaptability  to  meet  them,  and  above  all,  continued 
experience  rapidly  lessen  the  difficulties  in  the  study  of  disease  in  carlj-  life. 
Fortunately,  practice  enables  a  physician  to  make  an  examination  of 
many  unruly  children  almost  as  satisfactorily  as  of  those  who  are  quiet 
and  docile. 

Order  of  Procedure. — The  order  of  procedure  in  making  the  physical 
examination  depends  somewhat  on  circumstances,  and  the  greatest 
flexibility  in  the  plan  is  to  be  allowed.  Those  examinations  are  first 
made  either  which  arouse  least  objection  or  which  are  most  important. 
If  the  child  is  sleeping,  or  often  if  it  is  lying  awake  in  its  bed,  a  suptM-ficial 
inspection  of  it  may  be  made.  Under  the  same  circumstances,  the 
time  is  favorable  for  determining  the  character  of  the  radial  pulse  and  for 
the  palpation  of  the  abdomen,  for  should  the  infant  begin  to  cry,  satis- 
factory examination  of  the  abtlomen  is  rarely  possil)le.  Next,  the  tem- 
perature should  be  taken  before  its  elevation  can  have  been  increased  by 
prolonged  crying.     Following    this,    the   general   inspection    should    be 


186  THE  DISEASES  OF  CHILDREN 

completed,  the  child  being  undressed  for  this.     Should  crying  or  coughing 
occur  the  character  of  these  may  be  noted. 

The  phj^sical  examination  of  the  thorax  may  next  be  carried  on, 
auscultation  being  practised  first,  if  the  child  is  quiet,  since  this  often 
causes  less  alarm  and  less  tendency  to  cry  than  percussion  does.  At 
sometime  during  quiet  the  reflexes  may  be  tested.  Last  of  all  the  mouth 
and  throat  must  be  inspected  and  often  the  nose,  eyes,  and  ears.  The 
urine  should  be  obtained  for  examination  and  in  many  instances  the 
study  is  not  complete  without  an  examination  of  the  blood  and  of  the 
cavities  of  the  thorax,  abdomen,  or  spinal  canal  for  the  presence  of  fluid 
and  the  character  of  this.  Special  cases  require  a  radiological  and  bacterio- 
logical study. 

Some  of  these  methods  will  now  receive  consideration  in  fuller  detail. 
The  chnical  significance  of  the  observations  made  will  be  considered  in  the 
chapter  upon  Symptomatology  (p.  194). 

Inspection. — This  furnishes  often  greater  results  than  any  other 
method  for  arriving  at  a  diagnosis.  It  is  the  first  examination  to  be 
made,  and  begins,  although  at  a  distance,  as  soon  as  the  physician  comes 
into  the  presence  of  the  patient.  After  a  general  inspection  made  of  the 
child,  while  asleep  or  awake,  it  should,  when  possible,  be  undressed,  ■ 
wrapped  in  a  warm  blanket  and  laid  on  the  mother's  lap  or  on  the  bed. 
When  a  condition  of  exhaustion,  low  bodily  temperature,  the  presence  of 
pain  on  movement,  the  existence  of  diseases  of  the  upper  respiratory 
tract,  or  other  cause  renders  complete  undressing  undesirable,  the  body 
must  be  examined  part  by  part  throughout  before  the  study  is  ended. 
Unless  the  child  is  thus  undressed  very  valuable  data  would  be  necessarily 
undiscovered ;  such  as  differences  in  the  form  and  degree  of  motion  of  the 
two  sides  of  the  chest;  the  position  of  a  visible  apex-beat;  the  presence 
of  epigastric  episternal  pulsation  or  retraction;  the  occurrence  of  impor- 
tant eruptions  of  the  skin;  the  distention  of  the  abdomen  or  of  the 
abdominal  veins;  visible  peristalsis;  beading  of  the  ribs;  etc.  In  addition 
to  these  matters  inspection  must  take  cognizance  of  the  state  of  the  gen- 
eral nutrition;  the  physiognomy;  the  color  of  the  face  and  hps;  the 
shape  of  the  head;  the  condition  of  the  fontanelle  and  of  the  eyes;  the 
shape  of  the  abdomen;  visible  glandular  enlargement;  the  position  of 
the  body  in  bed;  the  shape  and  movements  of  the  hmbs;  the  condition 
of  the  genitals;  the  character  of  the  sleep;  the  degree  of  restlessness  or  of 
extreme  quiet;  the  method  of  nursing;  the  existence  of  nasal  or  oral  dis- 
charge; the  character  of  the  cough  and  cry  and  of  the  stools,  urine  and 
vomited  matter.  The  rate  and  rhythm  of  the  respiration  is  to  be 
determined;  the  occurrence  of  mouth  breathing  noted,  as  well  as  the 
existence  of  bronchial  rattling  which  can  be  heard  at  a  distance,  and  the 
presence  of  dyspnea  and  its  degree  and  method  of  manifestation  is  to  be 
studied.  The  character  of  respiration  and  its  regularity  may  be  observed 
well  by  watching  the  moving  of  the  thorax  and  abdomen  while  the  child 
is  asleep.     Nothing  can  be  determined  if  the  child  is  at  all  excited. 

Special  inspection  of  the  ears  is  often  required,  and  should  be  prac- 
tised in  all  doubtful  cases  where  there  is  unexplained  fever,  pain,  restless- 
ness or  stupor.  Examination  of  the  eyes  often  gives  valuable  information. 
The  presence  of  conjunctivitis  is  to  be  noted  and  of  swelling  and  discolora- 
tion of  the  lids.  The  use  of  the  ophthahnoscope  is  possible  even  in  very 
young  children,  and  important  conditions  of  the  eye-ground  may  often 
be  discovered.  Inspection  of  the  nose  with  the  mirror  and  speculum 
can  be  carried  out  in  docile  children.     That  of  the  anterior  nares  is  im- 


GENERAL  METHODS  OF  EXAMINATION  AND  DIAGNOSIS       187 


portant  and  unattended  by  difficulty.     It  may  reveal  the  presence  of 
nasal  diphtheria,  so  often  unsuspected. 

Inspection  of  the  mouth  and  throat  should  always  be  made  as  a  matter 
of  routine  at  the  first  visit,  and  the  possibility  of  subsequent  develop- 
ment of  disease  here  always  kept  in  mind.  The  condition  of  the  tongue, 
gums,  and  teeth  can  often  be  seen  if  the  patient  is  crying.  For  a  more 
thorough  inspection  of  the  mouth  in  infancy,  the  fingers,  previously  w^ell 
washed,  may  be  pushed  gently  in  between  the  gums  at  one  or  both  sides 
of  the  mouth.  This,  or  the  gently  pressing  of  the  chin  downward  will 
be  enough  to  open  the  mouth,  and  to  allow  a  visual  examination  of  it  to 
be  made  easily.  To  view  the  pharynx  satisfactorily  demands  quickness 
and  a  certain  degree  of  dexterity.  A  tongue-depressor  is  required,  and 
for  this  nothing  answers  better  in  family  practice 
than  a  teaspoon  with  a  smooth  handle  free  from 
sharp  irregularities.  Serviceable  for  office  use  are 
the  wooden  depressors  (Fig.  266)  made  for  this 
purpose,  and  in  occasional  cases,  where  consider- 
able force  is  required,  the  excellent  rigid  depressor 
devised  by  H.  D.  Chapin  (Fig.  26a). 

The  infant  or  young  child  should  be  seated  in 
the  mother's  lap,  facing  a  window.  Its  hands 
should  be  held,  or  better  still,  a  blanket  or  shawl 
be  wrapped  about  the  arms  and  body  close  under 
the  chin.  All  preparations  are  to  be  made  before 
the  physician  approaches  the  child.  In  this  way 
much  less  fright  is  occasioned.  He  now  stands 
slightly  to  one  side  and  in  front,  places  one  hand 
upon  the  head  in  order  that  he  may  steady  it  and 
turn  it  in  any  direction  desired,  and  with  the 
other  hand  introduces  the  depressor,  utilizing  a 
moment  when  the  child  opens  its  mouth  to  cry  or 
to  make  some  remonstrance.  With  older  children 
who  have  learned  to  keep  the  mouth  tightly  shut, 
the  spoon  can  readily  be  worked  in  from  the  side, 
or  the  nostrils  compressed  for  a  moment  to  make 
the  mouth  open.  Every  movement  must  be  gentle 
and  without  hurry,  yet  quickly  carried  out.  As 
soon  as  the  depressor  is  in  the  mouth,  it  is  pushed 
gently  backward.  When  it  reaches  the  base  of  the 
tongue  the  child  gags  and  necessarily  opens  its 
mouth  widely,  the  soft  palate  rising,  and  the  tongue  sinking.  At  this 
moment,  a  rapid  yet  complete  inspection  of  the  fauces  can  be  made. 
All  this  procedure  may  be  accompUshed  in  a  few  seconds.  The  only  ex- 
ception to  this  is  in  the  case  of  young  infants.  Here  the  reflex  gagging 
is  less  well-developed,  and  forcible  depression  of  the  tongue  is  required. 
It  is  in  such  cases  that  the  Chapin  depressor  is  serviceable. 

In  the  case  of  older,  vigorous,  and  very  obstreperous  children  who 
struggle  violently,  a  somewhat  different  plan  of  holding  is  rcciuired. 
The  mother  seats  herself  facing  the  light,  with  the  child  in  her  lap  and  its 
back  against  her  body.  Wrapping  her  knees  about  its  feet  and  legs  she 
grasps  its  left  hand  in  her  right  and  its  right  in  her  left  and  draws  them 
toward  her.  This  movement  crosses  the  child's  arms  over  its  chest 
and  draws  its  head  against  the  mother's  breast,  thus  rendering  the 
patient  powerless.     When  the  physician  wishes  to  have  both  of  his  hands 


Fiu.    26. — Tongue 

Depressors. 

(a)   Chapin's;   (6) 

Wooden. 


188 


THE  DISEASES  OF  CHILDREN 


free  for  the  treatment  of  the  throat,  a  mo(lifi(;ation  of  this  method  can  be 
adopted,  as  shown  in  the  illustration  (Fig.  27). 

Occasionally  timid  httle  children,  who  have  learned  to  fear  a  depressor 
will  tolerate  the  physician's  little  finger  pressed  for  a  moment  against 
the  base  of  the  tongue.  The  finger  must,  of  course,  be  well  cleansed 
immediately  before  its  insertion.  The  possibility  of  having  the  finger 
bitten  must  not  be  forgotten.  Some  children  will  themselves  depress 
the  tongue  with  their  own  finger.     Under  certain  circumstances,  as, 

for  instance,  in  cases  of  extreme  weak- 
ness, it  is  often  best  to  omit  the  exami- 
nation of  the  throat  unless  it  cannot  be 
foregone. 

The  inspection  of  the  larynx  in  in- 
fancy and  childhood  is  often  important. 
It  is,  however,  generally  difficult  to  ac- 
complish satisfactorily  in  young  subjects, 
even  by  skilled  observers. 

Palpation.- — In  palpating  a  young 
child  it  is  important  to  avoid  causing 
alarm.  The  hand  of  the  physician  should 
be  warm  and  every  touch  light.  When 
the  child  is  asleep  it  is  well  to  attempt 
to  take  the  pulse  or  to  palpate  the  ab- 
domen. To  examine  the  pulse  of  the 
sleeping  child  the  warm  fingers  may  be 
appHed  very  lightly  over  the  radial 
artery,  and  the  physician's  hand  should 
readily  follow,  without  restraining,  any 
movements  of  the  hand  of  the  patient. 
If  the  child  is  awake  its  attention  may 
often  be  diverted  by  toys.  If  it  be- 
comes alarmed  observations  of  the  pulse 
are  rendered  worthless.  In  infants 
under  6  months,  it  is  often  impossible  to 
feel  the  radial  pulse.  In  such  cases  it 
may  be  counted  at  the  fontanelle.  With 
similar  precautions  the  rate  of  respira- 
tion may  be  determined  by  placing  the 
hand  upon  the  abdomen. 

To  palpate  the  abdomen  satisfac- 
torily it  is  necessary  that  its  walls  be  relaxed.  During  sleep,  or  when 
the  child  is  being  diverted  in  some  way,  is  the  time  to  be  preferred. 
The  flat  of  the  warm  hand  should  be  laid  gently  upon  the  skin  under  the 
clothing  or  blanket.  Light  palpation  is  employed  first,  in  order  not  to 
awaken  resistance  of  the  abdominal  walls.  Local  tenderness  may  be 
discovered  and  the  degree  of  any  unusual  resistance  may  be  gauged. 
The  edge  of  the  hver  or  of  an  enlarged  spleen  may  be  detected,  and  any 
tumors  superficially  lying  can  often  be  readily  felt.  Now  deeper  palpa- 
tion may  be  attempted.  If  this  causes  resistance  and  the  child  cries  the 
hand  may  sink  a  little  deeper  every  time  a  breath  is  taken,  and,  by  main- 
taining the  advantage  thus  gained,  even  conditions  deep-seated  within 
the  abdomen  may  sometimes  be  detected.  The  value  of  bimanual  pal- 
pation is  not  to  be  overlooked.  Sometimes  rectal  examination  may  aid 
greatly  a  simultaneous  palpation  of  the  abdomen  with  the  other  hand. 


Fk;.   27. — Method  of  Confining 
THE   Arms   and   Legs  to  Permit  of 
Examination  of  the  Throat. 
(Freeman,  Philadelphia  Polyclinic, 
1895,  March  23.) 


GENERAL  METHODS  OF  EXAMINATION  AND  DIAGNOSIS       189 

It  is  often  better  to  do  this  under  anesthesia.  When  a  child  continues 
to  scream  violently  and  continuously,  abdominal  palpation  is  generally 
unsatisfactor3\  At  times  by  keeping  the  hand  in  position,  and  diverting 
the  child,  an  opportunity  to  examine  may  after  all  be  obtained. 

In  palpating  the  chest,  one  seeks  for  the  position  of  the  apex  beat, 
differences  in  the  expansion  of  portions  of  the  thorax,  the  presence  of  the 
rachitic  rosary  or  other  bony  alterations,  bulging  or  retraction  of  any 
region,  the  presence  of  precordial  thrill,  and  the  fremitus  com.municated 
by  bronchial  ronchi  and  less  frequently  by  the  voice.  Sometimes 
bimanual  palpation  in  an  intercostal  space  may  detect  fluctuation  in 
cases  of  pleural  effusion.  Palpation  is  a  most  important  means  of  diag- 
nosis in  cases  of  retro-pharyngeal  abscess  as  also  of  adenoid  vegetations 
in  little  children.  In  either  condition  the  finger  introduced  into  the 
nasopharynx  will  render  the  diagnosis  easy. 

Percussion.— This  must  always  be  Hghtly  performed.  Not  only 
is  heavy  percussion  a  cause  of  discomfort,  but  it  defeats  its  own  object. 
The  chest- walls  of  the  child  are  so  thin  that  a  heavy  blow  causes  a  general 
reverberation  and  conceals  the  dullness  of  a  small  spot  which  would 
otherwise  have  become  apparent.  The  finger  used  as  a  pleximeter  should 
be  firmly  applied,  but  the  percussion  should  be  done  gently  and  with  but 
one  finger,  and  with  a  movement  of  the  finger  only  or  the  slightest  action 
of  the  wrist.  The  feeling  of  the  resistance  is  as  important  as  the  hearing 
of  dullness  present.  Crying  causes  no  real  difficulty,  as  the  tapping  can 
be  done  at  the  moments  the  child  stops  to  draw  breath.  When  there 
is  no  crying,  percussion  should  always  be  made  during  both  inspiration 
and  expiration.  In  percussing  the  back  or  the  axillae,  the  child  may  sit 
in  the  lap  or  in  the  bed;  or,  in  the  case  of  infants,  ma}^  be  held  upright 
in  the  nurse's  arms  with  its  head  looking  over  her  shoulder.  In  either 
case,  however,  it  is  very  important  to  see  that  its  position  is  straight; 
not  with  one  arm  greatly  elevated  as  compared  with  the  other,  or  with 
the  spine  at  all  twisted.  A  faulty  position  will  give  untrustworthy  results. 
Indeed,  a  chest  much  deformed  from  spinal  disease  often  cannot  be  per- 
cussed with  satisfactory  results.  A  child  too  ill  to  be  kept  in  a  sitting 
position  may  be  placed  flat  on  its  abdomen.  This  position  may  some- 
times conveniently  be  made  use  of  in  less  feeble  patients,  since  it  is  one  to 
which  healthy  infants  are  accustomed  in  being  dressed.  For  the  examina- 
tion of  the  front  of  the  chest  the  child  may  conveniently  be  laid  on  its 
back  in  bed.  Percussion  should  not  be  too  long  continued,  in  order  that 
too  great  annoyance  or  fatigue  may  not  result. 

Percussion  is  not  so  satisfactory  in  children  as  in  adults,  owing  to  the 
smaller  and  more  resilient  chest  and  to  the  variety  of  sounds  produced. 
It  is  extremely  easy  entirely  to  overlook  small  areas  of  consolidation. 
Even  considerable  pleural  effusion  may  give  no  very  dull  sound.  On 
the  other  hand,  it  is  not  uncommon  to  discover  areas  of  apparent  dullness 
with  which  there  are  neither  symptoms  nor  other  physical  signs  to  corre- 
spond, and  which  have  no  pathological  significance,  as  far  as  can  be  dis- 
covered. This  is  especially  true  for  the  apices,  as  has  been  jjointod  out 
clearly  V>v  Hamill^  and  by  Mielke.-^  Among  other  i)cculiaritios  of  per- 
cussion in  healthy  children  is  the  loud,  full  note  ol)tained  over  the  whole 
chest,  which  would  be  called  tympanitic  in  adults.  A  cracked-pot  sound 
is  often  easily  obtainable  even  in  perfectly  healthy  children  who  are  cry- 
ing, or  even  who  are  entirely  quiet.     (See  also  p.  199.) 

1  .Vrch.  of  Ped.,  1907,  XXIV,  t)2. 
-lierl.  kliii.  Woch.,  1914,  LI,  1218. 


190  THE  DISEASES  OF  CHILDREN 

These  difficulties  and  causes  of  uncertainty  in  no  way  militate  against 
the  importance  of  a  careful  percussion  of  every  chest  in  which  disease 
is  suspected,  since  this  examination,  combined  with  experience  in  disease 
in  children,  will  often  be  of  the  greatest  possible  service. 

Percussion  of  the  abdomen  reveals  the  presence  of  unusual  gaseous  dis- 
tention, free  fluid,  enlargements  of  organs,  morbid  growths,  or  inflamma- 
tory processes  (p.  200). 

Auscultation. — Auscultation  of  the  lungs  in  children,  and  especially 
in  infants,  may  well  be  done  with  the  ear  apphed  next  to  the  chest  or  with 
only  a  thin  unstarched  garment  between.  This  method  is  suitable  when 
we  are  seeking  for  the  presence  of  the  scattered  coarse  rales  of  a  bronchitis, 
or  for  large  areas  of  bronchial  or  of  feeble  breathing;  but  for  the  more 
exact  localization  of  sounds,  or  the  discovery  of  lesions  in  doubtful  cases, 
a  stethoscope  is  indispensable.  Yet  both  the  mediate  and  the  immediate 
method  should  always  be  followed,  for  it  sometimes  happens  that  sounds 
undiscovered  by  the  one  will  be  revealed  by  the  other.  Either  the  disc, 
double  stethoscope  or  that  with  the  ordinary  bell-piece  may  be  employed, 
according  to  the  preference  of  the  examiner.  Children  often  dislike 
greatly  not  only  the  appearance  of  the  instrument,  but  also  the  sensation 
of  the  hard  cold  bell-piece  pressed  against  the  skin.  The  first  difficulty 
can  be  overcome  by  allowing  the  child  to  handle  or  play  with  the  stetho- 
scope before  it  is  used;  the  second  by  warming  the  part  which  is  to  touch 
the  chest,  or  by  having  it  covered  with  a  soft  rubber  ring  or  surrounded 
by  a  rubber  cup.  The  bell  must  be  small  in  order  to  make  it  adapt  itself 
well  to  the  surface  of  a  child  at  all  thin.  The  use  of  the  soft  rubber 
referred  to  is  an  aid  to  this.  The  whole  chest-piece  ought  to  be  short  in 
order  to  make  shifting  of  the  stethoscope  easier.  The  posterior  part  of 
the  chest  should  always  be  auscultated  first,  not  only  because  it  is  the 
more  fruitful  in  auscultatory  signs,  but  because  it  may  be  examined  more 
quietly  before  the  child  discovers  what  is  going  on.  Yet  all  parts  must  be 
carefully  studied,  never  forgetting  the  axillse.  The  cliild  may  be  seated 
or  held  in  the  arms  for  the  examination  of  the  back.  Infants  may  some- 
times lie  on  the  abdomen  upon  the  mother's  knees.  When  the  child  is 
too  ill  to  sit  up,  it  may  be  made  to  lie  on  the  abdomen,  or  first  on  one  side 
and  then  on  the  other.  This  last  method  is,  however,  less  satisfactory, 
as  it  prevents  immediate  comparison  of  regions  on  opposite  sides  of  the 
chest.  The  lateral  portions  are  best  examined  while  the  patient  is  sitting 
or  held;  the  front  while  it  is  lying  in  bed.  The  child  must  never  be  so  low 
that  the  position  of  the  physician  is  made  uncomfortable  through  stooping, 
as  otherwise  the  congestion  produced  interferes  with  exact  hearing  and 
accurate  results  cannot  be  obtained. 

Crying  does  not  interfere  materially  with  auscultation  of  the  lungs,  if 
the  ear  is  at  all  practised.  Inspiration  can  be  listened  for  when  the  child 
draws  breath  between  the  cries,  unless  there  is  noisy  laryngeal  inspiration. 
In  fact,  crying  is  often  advantageous  in  making  inspiration  deeper,  and 
it  is  frequently  only  during  crying  that  vocal  resonance  can  be  properly 
studied  in  infancy.  Increase  of  vocal  resonance  may  sometimes  be 
determined  by  observing  the  closeness  of  the  rales  to  the  ear  in  a  certain 
locality.  Auscultation  of  the  heart-sounds  is  interfered  with  consider- 
ably when  the  child  cries.  They  can  then  be  heard  only  when  the  child 
inspires.  The  irregularity  ift  respiration,  especially  present  in  infants, 
is  to  be  borne  in  mind,  as  the  very  long  pauses  which  occur  might  deceive 
the  unwary  into  beUeving  that  respiration  was  inaudible. 

Among   some  of  the  peculiarities  of  auscultation  in  childhood,  the 


I 


GENERAL  METHODS  OF  EXAMINATION  AND  DIAGNOSIS      191 

loudness  and  harshness  of  the  respiratory  murmur  is  to  be  mentioned,  a 
condition  which  when  present  in  adults  is  denominated  "puerile"  and  is 
considered  pathological.  In  infancy,  however,  respiration  is  superficial 
and  feeble.  The  ease  with  which  the  heart-sounds  can  be  heard  at  the 
back,  and  in  fact  all  over  the  thorax,  even  when  there  is  no  consoUdated 
pulmonary  tissue  intervening,  and  with  which  rales  and  even  bronchial 
respiration  produced  in  one  lung  can  sometimes  be  heard  in  the  other  is 
to  be  noted,  as  is  also  the  facile  transmission  through  the  lungs,  especially 
to  the  apices,  of  sounds  produced  in  the  upper  respiratory  tract.  It  is 
especially,  too,  in  children  that  respiration  approaching  a  bronchial  char- 
acter is  heard  under  the  clavicles  and  in  the  interscapular  spaces  close 
to  the  spine,  particularly  on  the  right  side,  yet  without  pathological 
significance. 

The  results  of  auscultation  in  pneumonia  in  early  life  often  present 
important  differences  from  those  obtained  in  adults.  This  is  so  true  that 
the  diagnosis  of  this  disease  must  often  rest  upon  the  symptoms  rather 
than  physical  signs.  The  lateness  of  the  development  of  physical  signs 
is  often  characteristic,  for  the  attack  may  sometimes  nearly  run  its  course 
before  any  signs  whatever  can  be  detected.  This  is  perhaps  especially 
true  in  bronchopneumonia,  in  which  disease  the  smallness  of  scattered 
patches  may  produce  no  characteristic  alteration  of  the  respiratory 
murmur.     (See  p.  199.) 

Temperature-taking. — The  effort  to  determine  the  existence  or  non- 
existence of  fever  by  applying  the  hand  to  the  skin  is  entirel}^  too  un- 
trustworthy. High  temperature,  it  is  true,  can  often  be  detected  if  the 
hand  is  placed  undej-  the  clothing  upon  covered  parts  of  the  body,  but  the 
method  has  repeated  y  led  to  grave  mistakes.  The  use  of  the  chnical 
thermometer  is  the  only  means  to  be  relied  upon.  For  employment  in 
children  it  is  much  better  to  have  one  which  will  record  quickly.  The  one- 
minute,  or  still  better  the  half-minute,  thermometer  is  to  be  preferred, 
allowing  it  to  remain  in  place  a  trifle  longer  in  order  to  insure  a  reason- 
ably accurate  record.  The  only  absolutely  accurate  method  consists  in 
leaving  the  instrument  in  position  until  the  maximum  temperature  is 
reached,  watching  the  mercury  meanwhile  to  determine  this.  The  dishke 
of  most  small  children  to  temperature-taking  is,  however,  too  great  to 
permit  of  employing  this  plan.  A  Httle  experimenting  with  a  quick  self- 
registering  thermometer  will  show  how  long  it  generally  requires  to  reach 
the  maximum  with  approximate  correctness. 

In  well-trained  children  of  4  years  the  thermometer  may  be  placed  in 
the  mouth,  although  there  is  even  then  some  danger  of  having  it  bitten. 
In  younger  subjects  the  rectum  is  the  only  proper  place.  The  use  in  the 
axilla  reciuires  very  variable  times  and  gives  varying  results,  owing  to 
the  difficulty  in  getting  close  apposition  of  the  opposing  cutaneous  sur- 
faces. This  is  especially  true  of  wasted  children.  Moreover,  this  local- 
ity requires  that  the  arm  be  held  firmly,  and  to  this  children  strongly 
object.  It  must  be  remembered  that  the  temperature  in  the  mouth  or 
rectum  during  fever  is  at  least  a  degree  higher  than  that  in  the  axilla,  even 
when  the  latter  is  accurately  ascertained.  The  employment  of  the  groin 
or  of  the  popliteal  space  is  to  be  condemned.  The  results  are  seldom 
accurate. 

The  bull)  of  the  thermometer  should  be  slightly  oiled  and  pushed  into 
the  rectum  until  well  out  of  sight,  the  infant  meantime  lying  in  any  posi- 
tion comfortable  to  it.  The  nurse  should  then  keep  the  tip  of  her  fing(»r 
upon  the  end  of  the  instrument.     There  is  no  necessity  of  restraining  the 


192  THE  DISEASES  OF  CHILDREN 

infant's  legs,  and  it  may  be  allowed  without  danger  to  kick  all  it  desires  if 
the  hand  merely  guards  the  thermometer.  It  is  better  that  the  rectum 
be  empty  of  feces,  but  this  is  not  an  essential.  Only  when  the  ther- 
mometer in  the  rectum  produces  pain  and  straining,  as  in  some  cases  of 
diarrheal  disturbance,  should  the  axilla  be  used  for  obtaining  the  record. 
The  time  for  taking  the  temperature  should  not  be  after  a  hard  attack  of 
crying,  as  the  height  of  it  may  be  increased.  For  the  same  reason,  crying 
during  the  observation  should  be  prevented,  if  possible,  by  diverting  the 
child. 

Examination  of  the  Urine.- — The  obtaining  of  the  urine  is  often  a 
matter  of  some  little  difficulty  in  infancy.  In  the  case  of  male  infants  it 
may  be  procured  by  applying  a  condom  over  the  penis,  or  a  small  bottle 
with  a  sufficiently  wide  neck  which  may  be  held  in  place  by  bandages  or 
adhesive  strips  extending  to  the  waist.  For  female  infants  the  neck  of 
the  bottle  may  be  passed  through  an  oblong  piece  of  adhesive  plaster, 
firmly  attached  there  in  a  way  to  prevent  leaking,  and  the  plaster  then 
applied  over  the  vulva  and  perineum.  In  some  cases  it  may  suffice  to 
place  a  large  wad  of  absorbent  cotton  inside  the  diaper  immediate^ 
under  the  genitals.  The  child  must  then  be  examined  frequently  in 
order  that  the  urine  may  be  expressed  from  the  cotton  as  soon  as  possi- 
ble after  it  has  been  passed.  The  method  is  not  very  satisfactory.  Still 
another  device  is  to  allow  the  child  to  lie  for  a  time  upon  a  rubber-cloth 
and  without  a  diaper,  or  upon  a  small  circular  mbber  air-cushion  with 
a  hole  in  the  center  and  a  small  pus-basin  placed  under  the  hole.  The 
surrounding  portion  of  the  bed  is  built  up  with  pillows  to  the  level  of  the 
cushion,  and  the  infant,  with  diaper  removed,  allowed  to  lie  upon  the 
bed  and  cushion  until  the  urine  is  passed  into  the  basin.  Children  a 
year  old,  or  sometimes  less,  may  be  put  at  frequent  intervals  on  a  chamber 
in  the  hope  of  procuring  urine  in  this  way.  In  the  event  of  none  of  these 
methods  succeeding,  a  small  silk  catheter,  No.  9  or  10  French  scale  or 
No.  4  American  scale,  may  be  employed.  Except  in  very  young  infants, 
and  sometimes  even  in  these,  the  instrument  can  be  passed  without  diffi- 
culty. The  greatest  precautions  must  be  taken  against  infection,  and  the 
method  employed  only  when  the  obtaining  of  uncontaminated  urine  is 
necessary,  as  in  cases  of  suspected  pyelitis  in  female  infants. 

Blood  and  Blood-pressure. — The  examination  of  the  blood  is  accom- 
plished as  in  adult  life,  testing  the  hemoglobin  percentage,  the  number 
of  and  changes  in  the  erythrocytes  and  leucocytes,  and  in  some  cases  the 
coagulability,  fragility  of  the  corpuscles,  specific  gravity,  and  any  chem- 
ical alterations  which  may  be  present.  The  blood-pressure,  too,  is 
estimated  as  in  adults,  with  such  modifications  of  the  apparatus  as  the 
smaller  size  of  the  patient  often  demands. 

Puncture  of  Serous  Cavities. — In  very  many  diseases  a  diagnosis 
cannot  be  made  without  the  puncture  of  the  pleural  or  peritoneal  cavity, 
or  of  the  spinal  canal.  The  procedure  is  easy  and  safe  if  proper  precau- 
tions are  taken.  A  glass  hypodermic  syringe  with  a  stout  needle  is  to  be 
employed,  or  one  of  the  larger  syringes  made  especially  for  the  purpose. 
Great  precautions  must  be  used  to  disinfect  thoroughly  the  instruments 
and  the  skin.  The  needle  and  syringe  should  be  thoroughly  boiled  and 
the  fluid  obtained  injected  into  a  sterilized  test-tube  and  stoppered  with 
scorched  cotton.  General  anesthesia  is  seldom  necessary,  and  even  local 
anesthesia  is  rarely  required,  the  discomfort  of  the  freezing  being 
greater  and  longer  continued  than  that  of  the  puncture.     Fuller  details 


GENERAL  METHODS  OF  EXAMINATION  AND  DIAGNOSIS      193 

regarding  the  employment  of  puncture  will  be  given  later.  (See  Empyema, 
Vol.  II,  p.  113,  and  Lumbar  Puncture,  Vol.  II,  p.  235.) 

Radioscopy. — Of  recent  years  the  use  of  the  x-raj^  for  purposes  of 
diagnosis  is  constantly  becoming  more  important.  Although  originally 
of  principal  value  in  surgery,  it  has  been  found  serviceable  as  an  aid  in 
medical  diagnosis  as  well.  The  outhnes  of  the  heart,  the  existence  of 
areas  of  pneumonia  or  of  tuberculosis,  the  presence  of  pleural  effusion, 
the  size  and  position  of  the  Uver,  and  other  physiological  and  pathological 
conditions  may  be  discovered  in  this  way.  A  verj-  serviceable  purpose 
of  the  fluoroscope  is  the  observation  of  the  movements  of  the  heart, 
lungs  and  stomach,  and,  with  the  aid  of  bismuth,  the  rapidity  of  the 
emptying  of  the  last-mentioned  organ. 

Electrical  Examination. — This  is  of  great  value  in  many  instances  of 
nervous  disease  for  the  determination  of  the  extent  and  nature  of  pa- 
ralyses of  different  sorts,  and  the  reaction  characteristic  of  a  spasmophilic 
state.  To  obtain  the  reactions  satisfactorily  it  is  sometimes  necessary  to 
give  an  anesthetic. 

The  Reflexes. — The  knee-jerks  may  be  tested  when  the  child  is  sitting, 
diverted  on  its  mother's  lap.  A  good  plan  is  to  support  the  foot  with  one 
hand.  Any  jerk  which  occurs  can  then  be  felt  as  well  as  seen.  Another 
method  consists  in  grasping  the  thigh  with  one  hand  just  above  the  knee. 
In  this  wsij  the  contraction  of  the  quadriceps  extensor  muscle  can  be  felt 
readily.  The  knee-jerk  cannot  always  be  elicited  easily,  sometimes  owing 
to  the  flabbiness  and  weakness  of  the  muscles,  sometimes  to  the  difficulty 
in  obtaining  a  voluntary  relaxation  on  the  part  of  the  child.  The 
existence  of  ankle-clonus  and  of  the  Babinski  and  other  reflexes  of  the 
lower  extremities  should  be  investigated  and  sometimes  those  of  other 
parts  of  the  body  as  well.  The  matter  will  be  referred  to  again  in  the 
section  upon  Nervous  Diseases  (Vol.  II,  pp.  233,  322). 


13 


CHAPTER  IX 
SYMPTOMATOLOGY  AND  DIAGNOSIS 

The  characteristics  of  appearance  and  development  present  in  health 
have  already  been  considered  in  discussing  Anatomy  and  Physiology. 
The  symptoms  pertaining  to  diseased  states  in  early  life  and  the  signifi- 
cance of  these  may  now  be  reviewed  briefly.  A  more  complete  descrip- 
tion of  man}^  of  them  will  be  found  under  the  headings  of  the  individual 
diseases. 

SIGNIFICANCE  OF  SYMPTOMS 

Position  and  Movements. — A  child  with  a  commencing  illness 
which  is  attended  by  pain  or  fever  no  longer  exhibits  the  quiet,  motion- 
less sleep  of  health,  but  tosses  from  side  to  side.  When  awake,  too,  the 
natural  restlessness  is  in  like  manner  increased,  the  patient  wishing 
to  be  taken  from  bed,  put  back,  rocked,  or  carried  about  in  many  ways, 
indicating  the  excited  state  of  its  nervous  system.  On  the  other  hand  at 
the  beginning  of  an  infectious  disease  it  often  happens  that  the  patient 
will  lie  unusualty  still,  sleeping  constantly,  the  evidence  apparentlj'^  of  the 
toxic  state  existing.  All  movements  are  slow  in  debihtated  states,  and  a 
child  afflicted  by  very  profound  exhaustion  may  lie  for  hours  without 
motion,  with  its  face  directed  upward  instead  of  to  one  side,  as  it  com- 
monly is  in  health.  The  same  position  and  lack  of  motion  is  seen  in  coma 
from  any  cause. 

Restlessness  in  infancy  especially  during  sleep,  with  an  unusual  tend- 
ency to  kick  the  covers  away,  is  an  early  symptom  of  rickets.  Restless 
sleep  may  depend  upon  hunger,  pain,  nervousness,  great  fatigue,  noises 
or  light  in  the  room,  or  unusual  excitement  before  going  to  bed.  Later, 
restlessness  at  night  may  accompany  certain  forms  of  chronic  gastro- 
enteric indigestion.  An  intense  degree  of  restlessness,  called  "jactation, " 
may  occur  in  some  respiratory  diseases,  especially  those  of  the  larynx; 
in  a  state  of  acidosis  with  air-hunger;  in  severe  chorea;  great  cerebral 
anemia  and  sometimes  in  severe  attacks  of  infectious  disease  including 
sepsis. 

Orthopnea  may  attend  diseases  of  the  respiratory  apparatus  or  of  the 
heart,  the  child  resting  comfortably  only  when  propped  up  in  bed  or 
when  held  upright  in  the  nurse's  arms  with  its  head  against  her  shoulder. 
Sleeping  with  the  head  thrown  back  and  the  mouth  open  is  often  the 
result  of  obstruction  to  respiration  by  adenoid  growths.  A  rocking  of 
the  head  from  side  to  side  on  the  pillow  may  be  observed  in  infants  with 
rickets,  sometimes  in  meningitis  or  headache,  and  is  frequently  a  natural 
expression  of  an  intensely  nervous  state.  Keeping  the  head  bent  back- 
ward is  seen  in  basilar  meningitis  of  different  forms,  and  to  a  less  degree 
in  headache.  A  fixity  of  the  head  and  neck  also  attends  cervical  caries 
or  torticollis,  the  head  in  the  latter  condition  being  generally  turned  to 
one  side.  Boring  the  head  into  the  pillow  may  indicate  meningeal  dis- 
turbance. Lack  of  power  to  hold  it  erect  denotes  great  general  weakness, 
or  may  be  an  evidence  of  congenital  or  acquired  torticollis,  of  idiocy,  or 

194 


i 


SIGNIFICANCE  OF  SYMPTOMS  195 

of  some  other  nervous  disorder,  such  as,  in  later  childhood,  advancing 
Friedreich's  ataxia.  InabiUty  to  walk  may  be  the  result  of  idiocy,  of 
actual  paralysis,  or  of  a  pseudo-paralysis  dependent  upon  syphilis  or, 
oftener,  rachitis.  Failure  to  move  one  or  more  limbs  properly  may 
denote  paralysis,  but  may  equally  well  be  due  to  the  pseudo-paralysis  of 
rickets  or  syphilis,  or  depend  upon  congenital  dislocation  of  the  hip-joint, 
or  indicate  that  motion  is  avoided  because  painful,  as  in  infantile  scurvy. 
Lying  upon  one  side  sometimes  occurs  in  pleural  effusion  of  that  side. 
Lying  with  the  head  retracted,  the  back  hollowed,  the  knees  and  elbows 
flexed  and  the  arms  crossed  over  the  chest — the  so-called  "gun-hammer 
position"  (en  chien  de  fusil) — is  frequently  a  symptom  of  meningitis. 
Lying  upon  the  abdomen  may  indicate  abdominal  pain,  but  with  many 
children  it  is  only  a  habit. 

Often  an  infant  will  repeatedly  put  the  hands  fretfully  to  the  head 
when  there  is  headache,  to  the  mouth  when  pain  exists  there,  or  to  the 
ear  when  earache  is  present.  In  the  latter  condition  the  side  of  the  head  is 
frequently  held  pressed  against  the  pillow  or  the  mother's  breast.  Pulling 
at  the  ear  accompanied  by  fretfulness  may,  however,  be  only  a  nervous 
habit  in  a  child  suffering  from  rachitis  or  other  debilitating  disease. 
Rubbing  or  picking  at  the  nose  indicates  coryza  or  gastro-intestinal 
disturbance  or  is  a  neurotic  habit  merely.  Pulling  at  the  throat  some- 
times occurs  when  there  is  much  dyspnea.  The  violent  alternate  flex- 
ion and  extension  of  the  Hmbs  upon  the  trunk,  and  of  the  trunk  itself, 
accompanied  by  cUnching  of  the  hands  and  the  characteristic  cry, 
denotes  the  pain  of  colic.  The  keeping  of  the  thumbs  drawn  into  the 
palms  and  the  toes  flexed  or  rigidly  extended  often  indicates  impend- 
mg  convulsions,  and  it  is  also  present  in  tetany.  At  the  same  time 
it  is  to  be  borne  in  mind  that  every  very  young  infant  has  a  tendency 
to  keep  the  thumbs  thus  inverted  much  of  the  time.  Rigidity  of  the 
limbs  may  occur,  as  in  meningitis,  cerebral  paralysis,  and  spinal  caries. 
More  or  less  extensive  tonic  spasm  may  be  seen  in  tetanus.  Irregular, 
jerking,  incoordinate  movements  in  older  children  occur  in  chorea. 
Clonic,  to-and-fro  movements  with  unconsciousness  are  characteristic 
of  convulsions,  while  true  ataxic  movements  are  seen  in  Friedreich's 
ataxia  and  alhed  conditions.  Tremor  is  rarely  observed  in  children, 
except  as  a  result  of  chorea,  some  organic  nervous  disease,  or  of  such 
weakness  as  develops  after  fever.  The  shaking  of  a  true  rigor  is  un- 
common in  early  childhood  and  infancy,  being  replaced  by  coldness, 
pallor,  drowsiness,  unusual  quiet,  or  a  convulsion. 

Surface  of  the  Body. — A  yellowish  tint  of  the  cutaneous  surface 
and  of  the  conjunctivae  is  seen  in  icterus.  Flushing  of  the  face  is  common 
in  fever,  and  is  also  often  observed  in  chronic  gastro-intestinal  indiges- 
tion of  older  children,  and  from  the  action  of  belladonna.  Shght  eczema 
or  chapping  of  the  cheeks  simulates  flushing  to  some  extent.  A  flush 
which  comes  and  goes  slowly,  on  the  face  or  on  a  part  of  it,  or  on  the  trunk 
when  exposed  to  the  irritation  of  the  air,  is  a  characteristic  symptom 
frequently  present  in  meningitis.  The  broad  red  hne  which  develops 
after  drawing  the  finger  over  the  abdomen  in  cases  of  meningitis  (tiiche 
cdrdbrale)  is  of  the  same  nature.  This  symptom  is,  however,  not  path- 
ognomonic but  only  suggestive  of  this  disease.  Very  marked  blucness  of 
the  whole  face,  the  fingers  and  toes,  and  the  mucous  membrane  of  the 
mouth,  is  present  in  congenital  cardiac  affections,  less  often  in  the 
intense  dyspnea  arising  in  laryngeal  stenosis,  and  sometimes  in  severe 
pneumonia.     A  slightly  bluish  tint  of  the  hps  and  checks  is  of  common 


196  THE  DISEASES  OF  CHILDREN 

occurrence  in  cases  of  post-natal  affections  of  the  heart.  The  red  flush 
present  on  the  cheeks  in  many  cases  of  pneumonia  quite  commonly  has  a 
bluish  tint  to  it.  Moderate  distention  of  the  veins  running  over  the 
scalp  and  at  the  root  of  the  nose  occurs  in  debilitated  children,  but 
especially  in  rickets.  The  veins  of  the  scalp  are  also  much  distended 
in  hydrocephalus.  Great  distention  of  the  veins  of  the  face  and  neck 
attends  any  decided  degree  of  dyspnea.  Dilatation  of  the  veins  over 
the  abdomen  and  lower  part  of  the  thorax  is  witnessed  in  cases  of  malig- 
nant abdominal  growth  or  sometimes  of  tuberculous  peritonitis.  A 
faintly  purplish  tint  of  and  under  the  eyelids  and  above  the  mouth  is 
often  seen  in  infants  with  debility  or  even  with  any  slight  disturbance 
of  health. 

Marked  pallor  of  the  skin  accompanies  nausea,  anemia  of  any  sort, 
rickets,  chronic  diarrhea,  chronic  suppurative  processes,  nephritis,  and 
frequently  heart  disease.  Combined  with  coldness  it  may  replace  in 
the  infant  the  chill  of  adult  life.  An  earthy  color  is  frequently  observed 
in  severe  chronic  diarrhea  and  a  brownish-yellow  color  of  the  skin, 
especially  of  the  projecting  portions  of  the  face,  in  congenital  syphilis. 
The  various  eruptions  of  the  exanthematous  fevers  are  oftenest  witnessed 
in  children,  since  these  diseases  are  far  commonest  at  this  age.  Infants 
show  an  especial  tendency  to  inflammations  of  the  skin,  such  as  miliaria, 
eczema  and  forms  of  erythema.  Profuse  sweating,  especially  of  the  head, 
is  an  early  symptom  of  rickets.  Coldness  of  the  extremities  is  present 
in  weakly  babies  with  poor  circulation  and  in  infants  suffering  from 
colic.  Clubbing  of  the  fingers  and  toes  occurs  in  congenital  cardiac 
disease  and  in  chronic  affections  of  the  lungs  and  pleura.  A  shining 
red  appearance  of  the  palms  and  soles  in  young  infants  is  a  symptom  of 
inherited  syphilis,  while  peeling  of  the  skin  in  older  children,  seen  espe- 
cially about  the  fingers,  suggests  convalescence  from  scarlet  fever. 

Edema  of  the  skin,  especialty  of  the  face  and  feet,  may  indicate 
nephritis  or  valvular  disease  of  the  heart,  or  may  be  an  evidence  of 
extreme  malnutrition  and  feeble  circulation.  Angioneurotic  edema 
sometimes  occurs  in  children.  A  localized  asymmetrical  atrophy  of  the 
muscles  points  to  poliom^'^elitis  or  neuritis,  while  an  undue  development, 
especially  of  the  calves,  may  indicate  pseudo-hypertrophic  muscular 
dystrophy.  Local  swellings  of  the  joints  are  observed  in  all  forms  of 
arthritis,  and  the  swelling  about  the  joints  and  of  the  shafts  of  the  long 
bones  in  scurvy  is  not  to  V)e  forgotten.  Curvature  of  the  spine  of  various 
forms  may  be  dependent  upon  disease  of  the  vertebrae,  old  pleurisy,  un- 
equal length  of  the  limbs,  rickets,  or  faulty  positions  in  being  carried  or 
in  sitting.  General  wasting  in  infancy  is  oftenest  the  result  of  in- 
sufficient nourishment,  of  persistent  diarrhea  or  vomiting  or  of  chronic 
intestinal  indigestion.  In  some  cases,  however,  it  is  a  sign  of  tuber- 
culosis or  of  congenital  syphilis. 

Face  and  Expression. — ^The  mouth  is  open  during  sleep  in  cases  of 
adenoid  or  tonsilhii-  hypertrophy,  or  when  the  nose  is  obstructed  by 
secretion.  Chewing  movements  occur  when  there  is  indigestion  or 
inflammation  of  the  mouth.  A  general  puffiness  of  the  whole  face,  with 
redness  of  the  eyes,  is  often  present  during  pertussis  or  measles.  Puffiness 
is  also  witnessed  in  the  edema  of  advanced  marantic  conditions,  and 
especially  about  the  eyes  in  nephritis. 

Pain  is  expressed  during  sleep  by  contortions  of  the  face  of  various 
sorts.  Thus  there  is  sometimes  an  expression  of  pain  with  contraction 
of  the  brows  in  headache,  while  the  smiling  of  very  young  infants  during 


SIGNIFICANCE  OF  SYMPTOMS 


197 


sleep  often  signifies  abdominal  pain.  Discharge  from  the  nose  occurs 
in  coryza,  and  is  often,  also,  one  of  the  first  symptoms  of  nasal  diphtheria. 
The  "snuffles"  of  new-born  infants  suggest  congenital  syphilis.  In  older 
children  persistently  reddened  eyelids,  combined  with  a  swollen  upper 
lip,  wide  nostrils,  thick  nasal  discharge,  muddy  complexion,  and  enlarged 
cervical  lymphatic  glands,  may  indicate  the  existence  of  the  lymphatic- 
exudative  diathesis  with  tuberculosis,  a  combination  to  which  the  title 
"scrofulous"  was  formerly  appHed.  Wide-open  nostrils  moving  with 
every  inspiration  and  accompanied  often  by  an  anxious  expression  of  face 
are  observed  in  dyspnea,  most  commonly  from  pneumonia  or  from  sten- 
osing  affections  of  the  larynx.  Occasional  movement  of  the  nares  is, 
howev^er,  of  frequent  occurrence  in  healthy  infants.  A  flattened,  some- 
what sunken  bridge  of  the  nose  is  characteristic  of  congenital  syphilis, 
but  by  itself  is  not  sufficient  to  warrant  this  diagnosis.  In  atrophic 
conditions  in  infancy,  when  the  fat  has  largely  disappeared  or  there  has 
been  great  loss  of  fluid  through  diarrheal  dis- 
charge, the  face  becomes  lined  in  a  marvellous 
manner,  especially  when  the  child  cries,  suggest- 
ing the  features  of  a  very  old  man.  The  most 
prominent  of  these  lines  is  that  called  the  "nasal," 
extending  from  the  alee  of  the  nose  and  running  in 
a  half  circle  around  the  corners  of  the  mouth. 
Other  special  lines  have  been  described  but  have 
little  importance. 

In  severe  acute  disease,  atrophic  states,  or 
when  there  is  pain  or  indigestion,  the  eyes  may  be 
only  partially  closed  during  sleep.  Twitching  of 
the  lids  and  crossing  or  rolling  upward  or  outward 
of  the  eyes  indicates  impending  convulsions.  The 
eyes  in  hj^drocephalus  are  directed  downward, 
with  the  lower  part  of  the  iris  covered  b}^  the 
lower  lid  and  the  sclera  above  the  iris  visible. 
After  a  severe  acute  attack  of  diarrhea  or  vomit- 
ing the  tissues  about  the  eyes  shrink,  leaving  them 
peculiarly  large  and  staring  (Fig.  28).  The  pupils 
are  dilated  or  unequal,  or  sometimes  contracted 
in  meningitis  or  other  intracranial  disorder. 
Nystagmus  may  often  be  seen  under  these  conditions,  but  may  be  a 
purely  functional  disturbance  combined  with  spasmus  nutans  or  gyro- 
spasm.  Strabismus,  too,  is  frcfiuently  an  attendant  of  intracranial 
(hsease,  ])ut  is  equally  well  a  congenital  defect.  Keeping  the  eyes  shut 
or  turned  from  the  light  or  buricul  in  the  pillow  indicates  photophol)ia 
from  conjunctivitis,  keratitis,  or  headache  dependent  oftenest  on  menin- 
gitis. A  film-like  appearance  of  the  cornea  develops  in  children  who  are 
moribund.  Ulcers  on  the  cornea  often  occur  in  syphilitic  or  tuberculous 
children.  Tubercle  of  the  choroid,  choke-discs,  and  other  important 
iiiterocular  conditions  may  be  discovered  by  oplithahnoscopic  examination. 

Head  and  Neck. — \'arious  alterations  of  tlie  luvul  ai)peai'.  some  of 
which  add  to  the  aiteied  exjiression  of  the  face.  In  chronic  hydrocepha- 
lus the  head  is  globular,  the  foreliead  oveihangs,  and  th(>  face  looks 
small.  In  rickets  the  head  has  in  general  a  stjuare  or  oblong  form,  with 
the  top  flattened  and  the  frontal  and  parietal  eminences  unusually  larg(\ 
The  face  looks  small  and  is  given  a  somewhat  square  appearance  through 
the  widening  of  the  lower  jaw.     Asymmetrical  heads  aredue  to  the  pres- 


FlG.  I'S. —  St   NKi:\  '1  ISSIK 

About  the  Eyes. 

Facies  of  acute  diar- 
rhea and  vomiting;  girl 
aged  11  months.  (Thom- 
son, Clinical  Examination 
of  Sick  Children,  2d  Edi- 
tion, 15.) 


198  •  THE  DISEASES  OF  CHILDREN 

sure  by  forceps  or  oftenest  to  the  existence  of  rickets,  the  lying  too  much 
on  one  side  producing  the  deformity  in  the  latter  case.  Faulty  position 
may,  however,  produce  the  deformity  even  when  rickets  does  not  exist. 
Flattening  of  the  occiput  may  be  due  to  pressure,  the  result  of  the  rachitic 
infant  lying  too  constantly  upon  its  back.  Asymmetrical,  microcephalic, 
and  other  deformed  states  of  the  head  may  be  found  in  idiocy.  Spots  of 
thin  membrane-like  bone  (craniotabes)  may  occur  in  the  occipital  region 
of  infants  in  the  early  months  of  life.  The  fontaneile  is  unduly  prominent 
and  tense  in  hyperemia  of  the  brain  from  any  cause,  meningitis,  tumor, 
and  chronic  hydrocephalus.  It  is  very  large  with  the  sutures  open  in  the 
latter  disease,  as  it  is  to  a  less  extent  in  rickets.  It  is  depressed  in  con- 
ditions of  inanition  or  after  profuse  diarrhea,  and  especially  in  collapse. 
Not  infrequently  the  bones  of  the  skull  overlap  uilder  these  circumstances. 
The  fontaneile  closes  very  early  in  microcephalus  and  late  in  rickets.  A 
systolic  murmur  is  sometimes  audible  in  the  neighborhood  of  the  anterior 
fontaneile,  especially  in  cases  of  rickets.  It  may  also,  however,  some- 
times be  heard  in  some  healthy  children.  Tenderness  over  the  tragus 
and  over  the  mastoid  may  indicate  otitis.  Swelling  of  the  occipital  and 
superficial  cervical  glands  is  often  theresultof  inflammation  of  the  scalp; 
while  that  of  the  glands  below  the  body  of  the  jaw  commonly  attends 
affections  of  the  pharynx  and  nasopharynx.  A  fluctuating  swelling  in 
the  neck  may  be  due  to  abscess  of  the  glands  or  sometimes  to  a  retro- 
pharyngeal abscess  pointing  here.  The  hair  is  worn  from  the  back  of 
the  scalp  in  cases  in  which  there  is  much  rocking  of  the  head,  as  in 
rickets. 

Mouth  and  Throat. — Blueness  of  the  lips  has  already  been  alluded 
to  (p.  195).  Fissuring  around  the  mouth  may  be  a  symptom  of  congeni- 
tal syphilis.  Grinding  of  the  teeth  occurs  especially  in  infants  with 
cerebral  disease  or  suffering  from  convulsions,  but  it  is  also  heard  in  chil- 
dren with  slight  digestive  disturbance,  and  in  some  cases  seems  to  be  only 
an  insignificant  although  disagreeable  habit.  Notching  of  the  permanent 
upper  incisor  teeth  is  seen  in  congenital  syphilis.  The  mucous  membrane 
of  the  mouth  may  exhibit  mucous  patches  in  syphilis,  and  is  one  of  the 
earliest  sites  for  the  appearance  of  the  eruptions  of  some  of  the  infectious 
fevers.  A  hemorrhagic  swollen  condition  of  the  gums  is  seen  in  infantile 
scurvy.  The  tongue  is  coated  in  most  disorders  of  digestion,  but  in 
some  instances  is  bright  red  and  smooth.  It  is  coated  in  many  fevers; 
bright  red  with  prominent  papillse  ("strawberry  tongue")  in  scarlatina; 
worm-eaten  in  appearance  in  the  so-called  "geographical  tongue;"  cyan- 
otic in  congenital  heart  disease  and  shghtly  so  in  pertussis,  and  may, 
like  the  rest  of  the  mucous  membrane  of  the  mouth,  exhibit  the  lesions  of 
some  of  the  forms  of  stomatitis.  In  children  with  severe  cough,  and  espe- 
cially with  pertussis,  who  have  cut  the  lower  incisor  teeth,  ulceration  of 
the  frenulum  linguae  is  not  infrequent. 

Cleft  palate  is  a  congenital  defect,  while  perforations  are  generally 
the  result  of  congenital  syphiHs.  High  arching  of  the  palate  may  attend 
some  forms  of  idiocy,  but  may  also  be  present  in  children  with  perfect 
mental  condition.  It  is  not  infrequently  associated  with  deviation 
of  the  septum  and  the  pressure  of  adenoids. 

Thorax. — The  chest  in  rickets  is  small  and  exhibits  the  rachitic 
rosary  in  front  and  bulging  of  the  ribs  behind,  with  marked  depression 
in  the  lateral  regions.  On  horizontal  section  this  gives  the  well-known 
"violin  shape."  A  horizontal  depression  beneath  the  nipples  is  also 
characteristic  of  rickets,  especially  where  there  has  been  much  disturb- 


SIGNIFICANCE  OF  SYMPTOMS  199 

ance  of  the  respiratory  apparatus.  A  typical  pigeon-breast  is  due  often 
to  obstruction  to  respiration  by  adenoid  growths.  This  and  other  very 
great  deformities  of  the  thorax  may  be  the  result  of  curvature  of  the  spine. 
A  very  unusual  prominence  of  the  precordium  occurs  in  cardiac  hyper- 
trophy in  heart-disease  in  children.  Diminished  expansion  of  one  side 
with  lack  of  movement  of  the  intercostal  spaces  is  dependent  upon  pleu- 
ral effusion  of  that  side,  adhesions  from  a  former  pleurisy,  or,  in  a  lesser 
degree,  upon  pneumonic  consohdation.  Contraction  of  one  side  results 
from  old  pleural  adhesions.  Bulging  of  the  intercostal  spaces,  with  lack 
of  movement,  occurs  in  large  pleural  effusions;  yet  effusion  may  sometimes 
be  present  and  the  interspaces  still  move.  Decided  dyspnea  from  any 
cause  produces  in  children  great  retraction  of  the  interspaces  with  each 
inspiration.  The  degree  of  retraction  of  the  epigastrium  and  aU  of  the 
lower  portion  of  the  thorax  which  occur,  with  tugging  of  the  sterno- 
cleidomastoid muscles,  and  sinking  of  the  episternal  notch,  is  often 
remarkable  at  this  time  of  life.  It  is  generally  greatest  in  cases  of  stenosis 
of  the  larynx.  Yet  a  considerable  amount  of  moving  of  the  epigastrium 
combined  with  lower  thoracic  retraction  is  a  normal  accompaniment  of 
respiration  in  healthy  infants,  and  still  more  so  in  rachitic  subjects. 
Displacement  of  the  heart's  apex  bj'^  pleural  effusion  is  to  be  noted.  Dull- 
ness over  the  manubrium  of  the  sternum  or  between  the  scapulae  may  indi- 
cate the  presence  of  enlarged  bronchial  glands.  In  infancy  the  substernal 
dullness  may  be  produced  by  the  thymus  gland.  Other  regions  of  dull- 
ness of  small  size  may  be  occasioned  by  old  pleural  thickening,  encysted 
empyema,  areas  of  collapsed  lung,  or  small  pneumonic  patches.  More 
extensive  dullness  may  be  due  to  pleural  effusion,  pneumonia,  or  wide- 
spread pulmonary  collapse. 

An  unusually  deep  tympanitic  percussion  note,  or  a  Skodaic  tympany, 
may  indicate  in  children  the  presence  of  pneumonic  consolidation.  It 
may  persist  throughout  nearly  the  whole  attack.  A  cracked-pot  sound 
is  especially  often  heard  in  advancing  or  receding  pneumonia,  although 
it  is  often,  too,  present  in  healthy  lungs.  Localized  ringing  rales  of  un- 
usual loudness  and  nearness  to  the  ear  often  signify  pneumonic  consoli- 
dation. Feeble  respiration  over  one  side  of  the  chest  may  indicate 
pulmonary  collapse  or  pleural  effusion.  It  may,  however,  be  the  onl}'- 
discoverable  evidence  of  pneumonia  in  some  instances.  This  has  repeat- 
edly led  to  the  erroneous  supposition  that  that  side  was  affected  on  which 
the  loudest  respiration  was  heard.  In  other  cases  of  pneumonia  a  slight 
harshness  of  respiration  is  the  only  physical  sign.  The  frequency  with 
which  numerous  rales  occur  in  bronchitis  in  children  as  compared  with 
adult  life  is  another  interesting  feature.  Bronchial  respiration  generally 
denotes  consolidation,  but  only  when  accompanied  by  other  symptoms. 
As  already'  stated  it  may  often  be  heard  through  a  pleural  effusion,  and 
is  normally  present  to  a  certain  extent  in  certain  parts  of  the  lungs. 
(See  p.  190.)  In  the  supraspinous  fossae  it  may  at  times  be  a  sign  of 
enlarged  bronchial  glands. 

The  various  cardiac  murnmrs  hoard  offer  nothing  peculiar  in  child- 
hood to  be  mentioned  in  this  connection,  except  that  the  characteristics 
of  the  mumiurs  of  congenital  disease  of  the  heart  are  to  be  borne  in  mind, 
as  well  as  the  frequent  occurrence  of  accidental  murmurs.  These  will 
be  referred  to  in  considering  Diseases  of  the  Heart  (Vol.  II,  pp.  121,  158). 
A  very  distinct  precordial  thrill  occurring  in  a  young  infant  points 
strongly  to  congenital  heart  disease. 


200  THE  DISEASES  OF  CHILDREN 

Abdomen. ^ — ^Unusual  gaseous  distention  of  the  abdomen  is  a  common 
symptom  of  rickets  and  is  also  often  associated  with  coHc.  It  is  also 
present  in  wasting  disease  due  to  chronic  digestive  disorders,  is  a  con- 
stant attendant  upon  idiopathic  dilatation  of  the  colon  and  upon  some 
forms  of  indigestion  in  the  later  j'ears  of  early  childhood  and  is  often  a 
serious  sjnuptom  in  pneumonia.  Great  flatulent  distention  with  much 
tenderness  may  occur  in  peritonitis,  and  to  a  less  degree  in  inflammatory 
diseases  of  the  intestine.  Distention  by  liquid  is  noticed  in  tuberculous 
peritonitis  and  in  abdominal  dropsy  from  cardiac,  renal  and,  more  rarely, 
hepatic  disease.  Irregular  distention  by  solid  masses  occurs  in  tuber- 
culous peritonitis,  fecal  accumulation,  enlargement  of  the  liver  and  spleen, 
morbid  growths,  intussusception,  and  in  localized  inflammatory  pro- 
cesses. Marked  retraction  of  the  abdomen  is  seen  in  cholera  infantum, 
in  meningitis,  especially  of  the  tuberculous  variety  and  in  many  exhaust- 
ing diseases.  Absence  of  movement  during  respiration  may  be  due  to 
inflammation  or  to  paralysis  of  the  abdominal  walls.  The  outlines  of 
the  stomach  and  of  the  coils  of  intestine  may  often  be  detected  in  atrophic 
children  with  distention  and  great  thinning  of  the  alxlominal  walls. 
Quite  active  peristalsis  is  often  noticeable  in  cases  of  pyloric  stenosis  and 
of  intestinal  obstruction. 

Method  of  Sucking  and  Swallowing. — Sucking  is  often  almost 
impossible  when  the  nares  are  occluded,  as  by  severe  acute  coryza,  con- 
genital syphilis  or  unusual  adenoid  growth,  since  the  infant  cannot 
breathe  while  the  mouth  is  closed  on  the  nipple.  Harehp  or  cleft 
palate  hkewise  renders  sucking  difficult  or  impossible  on  account  of  the 
interference  with  the  production  of  the  necessary  vacuum  hi  the  oral 
cavity.  Refusal  to  nurse  after  making  a  short  effort  may  indicate  sore- 
ness of  the  mouth.  In  other  cases  it  shows  that  little  or  no  milk  is  ob- 
tained from  the  breast.  Swallowing  with  a  noisy  gulping  sound  and  with 
a  grimace  or  a  cry  of  pain  occurs  in  soreness  of  the  throat.  Sucking  for 
a  moment  and  then  stopping  to  breathe  attends  pneumonia,  while  entire 
refusal  to  suck  may  accompany  extreme  weakness  or  coma.  It  is  an 
unfavorable  sign.  Inabihty  to  swallow,  even  when  fed  by  a  dropper  or 
spoon,  is  seen  in  tetanus,  eclampsia,  stricture  of  the  esophagus,  and  in 
children  extremely  ill  from  exhausting  diseases.  Choking  over  the  food, 
with  inability  to  swallow,  occurs  in  severe  cases  of  retropharyngeal  ab- 
scess. Regurgitation  through  the  nose  indicates  pharyngeal  paralysis, 
oftenest  after  diphtheria. 

Respiration. — Acceleration  of  breathing  is  very  common  in  children, 
and  the  rate  is  out  of  all  proportion  to  that  which  similar  causes  would 
occasion  in  adults.  It  is  seen  in  fever  and,  very  markedly,  in  pneumonia, 
and  is  constantly  present  to  a  variable  degree  in  rickets,  even  when  there 
is  no  catarrhal  disturbance  of  the  respiratory  apparatus.  The  increase 
in  the  respiratory  rate  for  each  degree  of  temperature  is  approximately 
the  same  as  in  adult  life,  i.e.,  about  2}4  :1,  with  the  rate  of  increase 
slightly  greater  than  this  in  infancy  and  slightly  less  in  later  childhood 
(M.  S.  Cohen). ^  Any  excitement  will  accelerate  respiration  greatly  in 
infancy.  Dyspnea,  i.e.  labored  breathing — which  may  or  may  not  be 
rapid  as  well — may  occur  in  any  condition  which  interferes  with  proper 
aeration  of  the  blood.  It  is  most  typically  seen  in  stenosis  of  the  larynx 
from  diphtheria,  sometimes  in.  retropharyngeal  abscess,  and  in  cases  of 
foreign  body  in  the  trachea  or  bronchus.  It  may  occur  under  other  cir- 
cumstances also,  such  as  pneumonia,  pleurisy,   diseases  of  the  heart, 

^  Arch,  of  Pod.,  1905,  917. 


SIGNIFICANCE  OF  SYMPTOMS  201 

severe  anemia,  uremia  and  acidosis.  In  moderate  dyspnea  the  inspira- 
tion is  labored,  prolonged  and  noisy;  but  in  bad  cases,  the  expiration  has 
the  same  character  as  well.  Sometimes  the  rhythm  of  the  respiration  is 
altered,  and  instead  of  the  inspiration  being  the  louder  and  longer,  with 
the  pause  following  expiration,  the  latter  is  the  louder  and  more  accentu- 
ated and  the  pause  follows  a  short  inspiration.  This  is  oftenest  seen  in 
pneumonia.  It  may,  however,  sometimes  occur  in  healthy  infants  if 
excited.  A  catch  in  the  respiration  is  often  observed  in  abdominal  or 
thoracic  pain.  It  is  witnessed  very  characteristically  in  pneumonia  and 
pleurisy,  in  which  the  inspiration  is  short,  and  "catchy,"  and  is  followed 
by  a  moaning  expiration,  the  so-called  "expiratory  moan."  Snoring  at 
night  points  strongly  in  children  to  occlusion  of  the  nasopharynx  by 
adenoid  vegetations.  A  curious  spluttering,  gurgling  respiration  is  heard 
in  retropharyngeal  abscess.  The  natural  great  irregularity  of  the  respi- 
ration in  young  children,  and  especially  in  infancy,  is  much  increased  in 
cerebral  affections.  This  greater  irregularity  may  also  sometimes  be 
seen  in  painful  affections,  especially  of  the  chest.  Sighing,  with  unusual 
intermissions  in  the  respiration,  is  often  present  in  meningitis,  yet  it  may 
at  times  occur  in  healthy  infants.  A  respiration  approaching  the  Cheyne- 
Stokes  type  is  frequently  observed  in  early  life  in  disorders  of  the  brain, 
even  though  only  functional  in  character.  Although  commonly  of 
grave  import,  it  is  by  no  means  so  much  so  in  infancy  as  in  adult  life. 
Great  slowing  of  the  respiration  may  take  place  in  cerebral  diseases,  as 
in  coma.  It  also  occurs  in  narcosis  from  opium.  Frequent  yawning 
may  indicate  serious  failure  of  the  circulation  or  sometimes  impending 
syncope. 

Pulse. — The  pulse  becomes  more  rapid  in  febrile  conditions  and  undei' 
the  slightest  excitement.  This  last  is  so  true  that  it  is  almost  impossible 
to  come  to  any  conclusions  regarding  it  when  an  infant  i&  awake  unless 
entire  placidity  is  obtained.  Other  things  being  equal,  and  all  undue 
excitement  being  removed,  the  increase  for  each  degree  of  temperature 
is  not  so  great  as  in  adult  life,  and  the  younger  the  child,  the  less  is  the 
relative  augmentation,  the  increase  for  1  degree  Fahrenheit  being  about 
4  beats  of  the  pulse  during  infancy.  This  has  been  pointed  out  by 
Cohen.'  The  truth  of  this  statement,  which  is  contrary  to  the  opinion 
generally  held,  will  be  readily  a(hnitted  on  slight  consideration.  If  an 
infant  of  a  year  with  a  normal  pulse  rate  of  1 10  to  120  showed  an  increase 
of  10  beats  for  each  degree  of  temperature,  as  does  an  adult,  an  elevation 
of  105  degrees  would  produce  a  pulse  rate  of  180  to  190,  which  is  clearly  more 
than  is  usually  obtained  for  fever  in  otherwise  healthy  and  quiet  infants. 
The  relationship  of  the  rate  of  the  pulse  to  that  of  the  respiration,  which  is 
4  :  1  in  achilts  unaffected  with  any  disease  which  unduly  affects  either  one  or 
the  other,  is  altcMod  somewhat  in  infancy,  being  th(Mi  about  8  : 1  (S(iuire).- 
Tlie  natural  irregtihiiity  of  the  pulse  in  young  cliildren  becomes  nuich 
intensified  in  many  affections  of  the  bi'ain.  In  such  disorders  irregularity 
is  ohv.n  combined  with  decided  retardation.  The  pulse  is  to  a  less  extent 
irregular  in  pericarditis  and  often  in  chorea.  It  is  unusually  rapid  in 
scarlatina,  out  of  all  proportion  to  the  severity  of  the  attack,  and  slower 
than  would  be  expected  in  numy  cases  of  typhoid  fever.  It  nuiy  l)e 
shghtly  retard(Hl  in  nephritis  ant!  the  arterial  tension  is  increased.  The 
"trip-hammer"  pulse  of  aortic  regurgitation  occurs  in  childhood  as  in 

'Archives  of  Pediatrics,  190"),  <)lo. 

-Transiie.    ()l)s(et.  .^oc.  Lond.,  ISOS,  X,  2S0.     l^-l".,  ("olieii,  he.  cil. 


202  THE  DISEASES  Of  CHILDREN 

adults,  and  the  capillaiy  pulse  of  this  disease  may  be  readily  obtained  in 
the  finger-nails  or  in  the  lips. 

Temperature. — Most  important  in  this  connection  is  the  observing 
of  the  ease  with  which  abnormal  alteration  of  temperature  takes  place  in 
early  life.  High  elevation  may  result  from  slight  causes,  such  as  consti- 
pation of  the  bowels  or  even  excitement.  Temporary  fever  is  not  un- 
common in  the  new  born.  (See  p.  302.)  More  or  less  elevation  may  be 
seen  in  children  with  moderate  debility,  especially  during  convalescence 
from  an  acute  disease.  The  variations  in  the  course  of  a  febrile  tempera- 
ture, including  the  difference  between  morning  fall  and  evening  rise,  are 
liable  to  be  greater  in  children  than  in  adult  Ufe.  Very  high  temperature 
may  attend  the  infectious  fevers,  some  of  the  cases  of  milk-poisoning,  and 
the  heat-exhaustion  occurring  in  very  hot  weather.  High  fever  of  short 
duration  is  borne,  as  a  rule,  better  in  childhood  than  in  adult  life. 

Depression  of  temperature  is  witnessed  in  such  conditions  as  critical 
fall,  severe  diarrheal  diseases,  collapse,  hemorrhage,  sclerema  neonatorum, 
congenital  heart  disease,  premature  birth,  and  in  very  many  cases  where 
insufficient  nourishment  is  taken  or  assimilated.  In  all  weakly  children 
the  temperature  is  readily  depressed  by  external  cold. 

Cry. — The  observation  of  the  cry  constitutes  one  of  the  most  im- 
portant methods  of  diagnosis  in  infants.  A  healthy,  comfortable  and 
contented  infant  does  not  cry.  A  cry  of  any  sort  always  has  a  meaning, 
even  though  it  indicates  nothing  more  than  some  shght  dissatisfaction. 
Persistent  violent  crying,  rather  fretful  than  sharp,  is  often  due  to  hunger. 
It  is  unappeasable  by  anything  except  the  giving  of  food,  when  it  ceases 
at  once  and  permanently.  Sometimes  a  cry  of  this  nature  is  in  reality 
dependent  on  thirst,  especially  if  there  has  been  severe  diarrhea.  .  A 
similarly  continuous  cry,  but  more  high-pitched  and  piercing,  attends 
persistent  severe  pain,  most  commonly  earache.  The  offering  of  food 
quiets  it  only  momentarily  if  at  all.  Pain  of  a  less  severe  nature,  the 
existence  of  the  intense  itching  of  eczema,  the  pain  from  the  pricking  by 
a  pin  concealed  in  the  clothing,  the  presence  of  a  wet  diaper,  and  many 
other  sources  of  discomfort  produce  obstinate  crying,  but  of  a  less  piercing 
and  violent  character.  The  cry  of  colic  is  very  violent,  but  more  or  less 
paroxysmal,  a  momentary  pause  being  followed  by  a  sudden  renewal 
without  discernible  reason.  It  is  attended  by  the  movements  of  the  body 
already  described  as  characteristic  of  colic  (p.  195).  The  giving  of  food 
may  quiet  it  for  a  time,  the  warm  milk  lulling  the  pain,  but  it  soon  re- 
turns as  bad  aa  before.  It  may  cease  suddenly  after  the  expulsion  of  gas 
from  the  stomach  or  bowel.  A  similar  cry  sometimes  attends  the  passage 
of  gravel.  A  sudden  acute  pain,  such  as  results  from  a  fall  or  other  slight 
accident  or  the  touching  of  some  tender  part,  produces  violent  but  tem- 
porary crying,  soon  appeased.  Crying  just  before,  with,  or  after  the 
evacuation  of  the  bowels  indicates  intestinal  pain,  or  sometimes  pain 
at  the  anal  opening.  Crying  may  also  attend  the  passage  of  urine  and 
may  denote  pain  in  the  bladder  or  the  irritation  of  scalded  areas  by  the 
secretion. 

A  weak,  peevish,  fretful  cry,  sometimes  almost  constant,  is  heard  in 
many  conditions  attended  by  much  debility.  Under  such  circumstances 
speaking  to  or  even  looking  at  the  child  may  start  the  cry.  A  louder  but 
fretful  cry  in  a  healthy  child,  often  attended  by  rubbing  of  the  eyes  with 
the  fists,  indicates  sleepiness.  An  almost  inaudible  cry  occurs  in  severe 
stenosis  of  the  larynx  and  in  cases  of  great  exhaustion.  Puckering  the 
face  into  the  position  for  crying  but  absolutely  without  sound  occurs  in 


SIGNIFICANCE  OF  SYMPTOMS  203 

these  conditions  when  extreme,  as  also  after  tracheotomy  or  intubation. 
The  absence  of  crying  is  witnessed  in  comatose  states.  There  is  also  very 
little  crying  accompanying  decided  dyspnea,  such  as  attends  severe 
pneumonia  or  pleural  effusion,  on  account  of  the  lack  of  air  for  it.  The 
cry  of  pneumonia  is  suppressed  and  short,  and  the  expiratory  moan  de- 
scribed in  considering  Respiration  is  often  heard  (p.  201).  Yet  children 
with  pneumonia  sometimes  cry  loudly  if  the  dyspnea  is  trifling.  As  a 
rule,  however,  loud  crying  indicates  that  there  is  little  wrong  with  the 
lungs.  Hoarseness  of  the  cry  is  heard  in  laryngitis,  and  a  hoarse,  whimp- 
ering, and  somewhat  nasal  cry  occurs  in  congenital  syphilis.  A  nasal  cry 
is  present  also  in  coryza  of  other  nature.  A  characteristic  "brazen" 
cry  is  heard  in  spasmodic  croup.  A  short  cry  of  pain  after  coughing 
denotes  pain,  as  in  pneumonia  or  pleurisy.  Crying  is  usually  unattended 
by  the  production  of  tears  until  about  the  3d  month.  After  this  date 
crying  without  tears  indicates  a  condition  of  dangerous  debility.  A 
sudden  shriek  at  intervals,  without  ordinary  crying,  uttered  by  a  child  in 
a  stuporous  state,  suggests  tuberculous  meningitis  (''hydrencephalic 
cry").  Sudden  crying  out  at  night  may,  however,  be  produced  by  the 
night-pains  of  disease  of  the  bones.  After  infancy  is  passed  violent, 
unappeasable  crying,  with  which  a  child  suddenly  starts  from  sleep,  is 
indicative  of  night  terrors.  In  later  infancy  and  childhood  the  cry  of 
anger  is  often  witnessed.  It  is  loud,  violent,  without  any  piercing  charac- 
ter, unattended  by  any  evidence  of  pain,  and  generally  associated  with 
some  evident  reason  for  wrath.  The  infant  while  crying  from  this  cause 
often  stiffens  itself  all  over,  or  throws  its  head  backward;  while  the 
older  child  may  stamp  its  feet,  throw  itself  upon  the  floor,  and  even  beat 
its  head  against  the  floor  or  wall.  Finally,  there  is  the  very  common  and 
very  deceptive  cry  occurring  in  infants  who  have  in  various  ways  not 
been  well  trained,  which  is  merely  an  expression  of  discontent  with  their 
condition,  although  without  anger  or  pain.  A  baby,  for  instance,  wakens 
from  sleep  and  cries  violently.  As  soon,  however,  as  it  is  taken  up  by  the 
nurse  its  crying  ceases,  and  smiles  replace  the  tears. 

Cough. — A  short  suppressed  cough  followed  by  a  facial  expression 
of  pain  is  heard  in  pneumonia  and  pleurisy;  a  pecuUar  barking,  brazen 
cough  in  spasmodic  croup  or  the  early  stage  of  laryngeal  diphtheria; 
a  tight  hoarse  cough  in  laryngitis  and  tracheitis.  Long,  hard  paroxysms 
of  dry  cough  sometimes  causing  pain  in  the  chest  occur  in  the  early  stages 
of  severe  bronchitis,  and  a  loose  rattling  cough  in  bronchitis  after  secre- 
tion is  established.  The  long  paroxysms  of  rapid,  short  expiratory  efforts, 
continuing  until  suffocation  seems  impending  and  followed  by  a  crowing 
inspiration,  are  characteristic  of  pertussis.  In  this  disease  mucus  is 
often  driven  from  the  mouth.  A  very  similar  cough  may  occur  in 
enlargement  of  the  bronchial  glands,  yet  not  often  accompanied  by  a 
whoop.  It  may  be  particularly  troublesome  at  night,  as  the  cough  in 
pertussis  is  likewise.  A  peculiarly  severe,  ringing,  brazen  cough,  in 
some  respects  resembUng  that  of  croup  but  oftcnjjparoxysmal,  is  some- 
times caused  by  the  presence  of  glandular  or  other  tumors  or  abscesses 
within  the  thorax,  or  the  presence  of  a  foreign  body  in  the  windpipe. 
An  annoying  "tickhng,"  hacking  cough  occurs  in  pharyngitis,  especially 
when  the  uvula  is  elongated.  When  the  pluiryngitis  is  severe  the  cough 
causes  pain  in  the  throat.  A''hard  chy  cough,  often  severe,  is  hoartl  in 
passive  congestion  of  the  lungs  i^roduced  by  (hseasc  of  the  iioart.  In- 
digestion is  frequently  attended  by  a  hacking  cough,  the  so-called 
"stomach  cough."     Asthma  has  a^shortdry  cough,  not  paroxysmal. 


204  THE  DISEASES  OF  CHILDREN 

Voluntary  expectoration  of  sputum  following  cough  does  not,  as  a 
rule,  take  place  in  any  disease  until  6  or  7  years  of  age.  Sputum  for 
examination  must  be  obtained  by  introducing  an  elastic  catheter  or  a 
pledget  of  cotton  or  cloth  on  an  applicator  to  the  base  of  the  tongue. 
This  occasions  coughing,  whereupon  the  sputum  may  be  aspirated  by  the 
catheter  or  caught  on  the  cloth. 

Pain. — Pain,  either  subjective  in  origin  or  produced  by  handling, 
is  of  the  most  varied  form  and  significance  in  early  life.  It  has  already 
been  discussed  to  some  extent  under  different  headings.  The  deter- 
mination of  the  seat  of  pain  in  infants  and  young  children  is  often  very 
difficult.  Frequently  tenderness  can  be  ascertained  by  handling  various 
parts,  and  observing  whether  a  cry  or  a  grimace  is  produced.  Children 
under  5  years  seldom  locate  pain  exactly  in  attempting  to  describe  it.  Pain 
in  the  head  is  very  common.  It  may  indicate  the  onset  of  fever,  whether 
this  be  of  short  or  of  more  prolonged  duration,  being  a  frequent  early 
symptom  of  typhoid  fever  and  still  oftener  of  meningitis.  It  is  common 
in  intracranial  tumor.  In  other  cases  it  is  dependent  upon  coryza, 
anemia,  dyspepsia,  eyestrain,  otitis,  fatigue,  excessive  mental  work  at 
school,  migraine,  dental  caries,  nephritis  or  heart  disease.  Pain  referred 
to  the  mouth  msiy  indicate  stomatitis  of  various  sorts,  or  toothache. 
In  the  throat  it  may  attend  many  forms  of  inflammation  there.  Pain 
in  the  neck  may  be  clue  to  inflammation  of  the  lymphatic  glands,  mumps, 
tonsillitis,  or  the  tenderness  of  the  muscles  in  torticollis.  It  may  also 
be  a  symptom  of  caries  or  of  basilar  meningitis,  especially  when  the  pain 
is  increased  by  motion.  Pain  in  the  thorax  depends  most  frequently 
upon  pleurisy  and  pneumonia.  It  may  then  be  present  only  during 
cough.  Occasionally  pain  in  one  side  is  produced  by  herpes  zoster. 
Heart-disease  is  sometimes  attended  by  severe  attacks  of  precordial 
pain.  Tenderness  of  the  chest  on  grasping  the  child  under  the  arms  to 
lift  it  may  occur  in  pleurisy,  but  is  most  marked  in  rickets,  probably  due 
to  a  scorbutic  complication.  The  symptom  may  be  deceptive,  as  the 
pain  can  be  in  reality  located  in  some  other  part  of  the  body,  which  the 
lifting  has  disturbed.  Pain  in  the  abdomen  depends  upon  digestive 
disturbances,  peritonitis,  appendicitis,  or  intussusception,  and  is  not 
infreciuently  a  symptom  of  spinal  caries.  Inflammatory  affections  of  the 
chest  quite  often  produce  a  pain  which  is  referred  to  the  abdomen.  Pain 
with  stiffness  on  moving  the  back  strongly  suggests  caries  of  the  spine. 
In  the  limbs  it  may  depend  upon  rheumatism  or  other  form  of  arthritis, 
or  on  poliomyelitis,  but  in  infancy  is  far  oftener  a  symptom  of  scurvy. 
It  becomes  particularly  evident  when  the  child  is  handled.  Pain  is 
liable  to  attend  inflammatory  affections  of  the  bones,  among  which  may 
be  mentioned  periostitis  and  osteomyelitis.  The  existence  of  undis- 
covered fractures  in  infancy  is  a  fruitful  and  puzzling  source  of  severe 
pain.  Hip-joint  disease  occasions  pain  which  is  referred  to  the  thigh  or, 
commonly,  to  the  knee.  Caries  of  the  spine  may  occasion  pain  in  the 
lower  limbs.  An  unusual  degree  of  local  or  general  hyperesthesia  is 
not  uncommon  in  dijfferent  nervous  disorders. 

Breath. — A  rancid,  butyric  acid  odor  may  be  present  on  the  breath 
of  infants  suffering  from  the  vomiting  of  gastric  indigestion.  Acute 
febrile  conditions  or  acute  indigestion  may  produce  the  odor  of  acetone, 
or  give  rise  to  other  odors  of  an  unpleasant  character.  Ozena,  ulcerative 
stomatitis,  the  accumulation  of  secretion  in  the  tonsils,  and  the  sputum 
from  puhnonary  abscess  and  from  bronchiectatic  cavities  can  produce  a 
very  offensive  odor,  while  in  gangrene  of  the  lung  and  in  noma  the  sick- 


i 


SIGNIFICAXCE  OF  SYMPTOMS  205 

ening  odor  is  almost  unbearable.  A  stercoraceous  breath  is  exceptionally 
noticed  in  intestinal  obstruction. 

Vomiting. — Vomiting  is  a  symptom  so  frequent  in  early  life  and 
due  to  such  varied  causes  that  it  will  receive  independent  consideration 
later  (p.  700).  In  this  connection  a  few  of  its  diagnostic  indications 
may  be  mentioned.  Simple  regurgitation,  without  effort,  of  food  which 
is  little  if  any  changed,  occurs  in  the  case  of  healthy  infants  who  have 
taken  more  milk  than  they  can  comfortably  hold,  or  who  have  been 
carelessly  handled  after  feeding.  True  vomiting  is  accompanied  by 
more  effort  and  by  evidences  of  nausea,  such  as  pallor  of  the  face  and 
perspiration.  It  is  very  common  at  the  beginning  of  acute  febrile 
diseases  in  early  life.  When  acute  and  of  brief  duration,  accompanied 
by  nausea  and  coated  tongue,  and  perhaps  followed  by  diarrhea,  it  is 
generally  the  sign  of  acute  gastro-intestinal  disturbance.  Very  obstinate 
vomiting,  frequently  with  much  mucus,  occurs  in  chronic  gastric  indiges- 
tion and  gastritis  in  infancy  and  in  cases  of  stenosis  of  the  pylorus. 
Vomiting  may  be  the  evidence  of  a  toxic  state,  as  seen,  for  instance,  in 
uremia  and  in  acute  milk-poisoning.  If  repeated  frequently  for  days, 
and  attended  by  retracted  abdomen,  headache,  moderate  fever,  and  some 
degree  of  constipation,  it  is  very  suggestive  of  meningitis,  or,  in  the 
absence  of  fever,  of  brain  tumor.  Recurrent  vomiting  is  a  disorder  not 
to  be  forgotten,  ^"omiting  is  common  after  violent  paroxysms  of  cough- 
ing, especially  in  pertussis  and  severe  bronchitis.  Very  obstinate 
vomiting  with  distention  of  the  abdomen  and  some  degree  of  constipation 
occurs  in  peritonitis.  When  obstinate  constipation  is  combined  with 
obstinate  vomiting,  the  existence  of  obstruction  of  the  bowels,  sometimes 
congenital,  may  be  suspected. 

Finally,  the  extreme  ease  with  which  vomiting  is  brought  about  in 
infants  and  in  children  must  be  borne  in  mind.  This  is  especially  true 
when  once  the  tendency  to  vomit  has  been  developed.  Thus  in  many 
infants  slight  moving  of  the  body  after  a  meal  is  sufficient  to  cause  the 
lo.ss  of  it.  The  mere  taste  of  the  food  may  occasion  vomiting,  both  in 
infants  and  older  children,  everything  being  ejected  the  taste  of  which  is 
not  liked.  This  is  probably  the  reason  why  nourishment  given  to  infants 
l)y  gavage  may  be  retained,  when  that  entering  the  mouth  in  the  usual 
way  may  be  vomited. 

Bowel-movements. — Alteration  of  the  character  of  the  feces  is 
common  in  disease  in  infancy.  A  large  amount  of  white,  lumpy  material 
in  the  stools,  especially  of  bottle-fed  infants,  generally  indicates  too  large 
an  amount  of  fat  in  the  food.  Mucus  appears  very  readily  in  the  stools 
of  infants.  It  may  indicate  merely  a  catarrhal  process,  ))ut  in  large 
amount  and  accompanied  by  fever  and  straining  sugg(\sts  an  infiannna- 
toiy  concHtion.  It  is  generally  present  in  considerable  amount  after  the 
achninistration  of  a  purgative,  such  as  castor  oil.  ]ih)od  in  the  passages 
may  denote  a  purely  local  process,  such  as  fissure,  hemorrhoids,  congestion, 
or  constipation.  Mixed  with  mucus  and  attended  by  straining  efforts  it 
may  be  the  evidence  of  enterocolitis  or  intussusception ;  and  wiien  in  larger 
amount,  without  mucus,  may  be  one  of  the  symptoms  of  jmrpura  htemor- 
rhagica,  severe  ulceration,  or  rectal  polypi.  Black  stools  suggest  the 
existence  of  hcmoirhage  in  the  upper  int(>s(inal  tract.  A  pea-grecMi  color 
is  often  physiological,  but  the  pi(>sence  of  dark-green  slimy  masses  is  very 
frecjuent  in  intestinal  indigestion  and  in  ejiterocolitis.  Put ty-colorcvl 
stools  may  be  due  to  deficiency  in  the  secretion  of  bile,  but  oftiMier  iti 
infancy  white  or  grey,  formed  or  unformed  stools  are  seen  in  those  who 


206  THE  DISEASES  OF  CHILDREN 

are  taking  much  more  butter-fat  than  they  can  digest.  Hard,  scybalous 
masses  coated  with  mucus  occur  in  older  children  with  forms  of  intestinal 
indigestion  of  a  chronic  nature.  Intestinal  parasites  of  different  sorts 
or  their  ova  may  frequently  be  discovered. 

The  odo7-  of  the  stools  during  disease  varies.  In  cholera  infantum  the 
passages  are  nearly  odorless;  in  other  forms  of  diarrhea  in  infancy  they 
may  be  sour  smelling  and  irritating  to  the  adjacent  skin,  or  may  be  very 
offensive,  the  difference  in  odor  depending  upon  whether  carbohydrate 
or  protein  indigestion  is  present.  The  administration  of  such  substances 
as  beef-juice  and  egg- water  often  produce  exceedingly  unpleasant  odors. 
The  action  of  certain  drugs  and  food  upon  the  color  of  the  passages  is  to 
be  remembered;  iron  producing  a  black,  and  bismuth  a  greenish-black 
hue,  and  such  substances  as  hematoxylon  and  krameria,  formerly  much 
in  use,  a  reddish  color.  Infants  fed  upon  a  high  carbohydrate-diet,  such 
as  malt-soup  or  buttermilk-mixtures,  exhibit  smooth,  brownish  stools. 
A  fuller  discussion  of  the  character  of  the  feces  in  disease  will  be  given 
later.     (See  p.  731.) 

The  number  of  passages  varies  greatly;  and  in  estimating  the  impor- 
tance of  this  matter,  the  character  and  amount  of  the  food  taken  must  be 
considered  carefully.  Constipation  in  infancy  is  sometimes  a  sign  of  a 
very  thorough  digestion  which  leaves  little  waste-material  to  pass;  in 
other  cases  it  may  depend  on  the  great  length  of  the  sigmoid  flexure  in 
early  hfe;  in  others  upon  impaired  general  health,  and  in  still  others,  when 
combined  with  a  failure  to  gain  in  weight,  it  is  caused  by  insufficient 
nourishment.  On  the  other  hand,  an  undue  number  of  movements, 
unless  diarrheal  in  character,  may  be  merely  a  natural  method  of  getting 
rid  of  an  excess  of  nourishment.  Frequent,  diarrheal  stools  may  be  due 
to  inflammatory  conditions  of  the  mucous  membrane,  or  tuberculous  or 
other  ulceration;  toxic  influences,  as  in  the  infectious  fevers;  local  irrita- 
tion such  as  improper  articles  of  food;  or  reflex  causes,  as  seen  in  diarrhea 
after  surface-chilling. 

Urine.  (See  also  Vol.  II,  p.  \QS.)— Retention  of  urine  maybe  depend- 
ent upon  the  pain  which  urination  causes,  as  in  vulvitis,  inflammation  of 
the  prepuce  or  glans,  or  the  smarting  produced  by  very  acid  urine.  Some- 
times it  is  the  result  of  obstruction,  as  in  cases  of  calculus  in  the  urethra, 
very  narrow  foreskin,  malformations  of  the  urinary  tract,  or  stone  in  the 
bladder.  Suppression  or  very  great  diminution  in  the  amount  of  urine 
may  attend  acute  nephritis,  acute  fever,  profuse  diarrhea,  severe  vomit- 
ing, renal  calculus,  and  sometimes  intestinal  obstruction.  Great  increase 
in  the  amount  of  urine  occurs  in  diabetes,  diabetes  insipidus,  after  crisis 
in  fever,  after  attacks  of  abdominal  pain  or  of  convulsions,  and  in  some 
forms  of  chronic  Bright's  disease.  Albuminuria  is  occasionally  physio- 
logical. It  occurs  also  in  Bright's  disease,  in  severe  cardiac  affections,  in 
many  febrile  states,  sometimes  in  scurvy,  and  from  the  admixture  of  pus 
or  blood.  Blood  in  the  urine,  unless  in  very  small  amount,  makes  it 
appear  smoky,  muddy  or  bright  red  in  color.  It  may  occur  in  Bright's 
disease,  scurvy,  in  some  grave  cases  of  infectious  fevers,  purpura,  stone 
in  the  bladder,  and  especially  in  stone  in  the  kidney.  Often  the  presence 
of  blood  manifests  itself  most  noticeably  by  a  stain  on  the  diaper. 
Sometimes  the  altered  color  is  due  to  hemoglobin  and  not  to  the  presence 
of  corpuscles.  This  is  true  of  infectious  hemoglobinuria  of  the  new 
born.  A  paroxysmal  hemoglobinuria  is  occasionally  seen  in  older 
children.  The  urine  is  of  a  reddish-yellow  color  in  jaundice.  Uric 
acid  sand  may  appear  on  the  diaper  of  infants,  while  in  other  cases 


SIGNIFICANCE  OF  SYMPTOMS  207 

an  excess  of  urates  makes  the  urine  of  infants  milky  in  color.  Pus  in 
the  urine  is  found  in  inflammation  of  any  part  of  the  urinary  tract,  as 
pyelitis,  cystitis  or  urethritis.  It  also  results  from  contamination  by  the 
discharge  in  vulvovaginitis. 

Blood. — The  significance  of  the  alterations  of  the  blood  in  disease 
depends  upon  the  variation  in  the  amount  of  hemoglobin,  and  in  the 
number  and  character  of  the  erythrocytes  and  particularly  of  the  leuco- 
cytes the  presence  of  pathological  corpuscles  and  not  infrequently  the 
alterations  shown  by  chemical  examination.  The  matter  can  best  be 
considered  in  connection  with  the  various  diseases  of  the  blood  (p.  000). 

Serous  Cavities. — By  the  puncture  of  the  pleural  cavity  the  existence 
of  effusion  is  made  known  and  the  character  of  the  fluid  determined.  The 
diagnosis  between  pneumonic  consolidation  and  pleural  effusion  often 
hinges  upon  the  result  of  this  procedure.  By  lumbar  puncture  the  exist- 
ence of  forms  of  meningitis  can  be  positively  determined  in  most  cases. 
The  diagnosis  of  the  nature  of  an  abdominal  disorder  may,  in  like  manner, 
be  aided  by  the  employment  of  puncture  in  some  instances. 

The  appearance  and  character  of  the  fluid  obtained  by  the  punc- 
ture of  serous  cavities  including  the  kind  of  formed  elements  present  in  it 
is  shown  by  microscopical  and  chemical  examination.  The  presence  and 
nature  of  any  bacteria  found  must  receive  careful  consideration.  The 
matter  can  better  be  studied  in  another  connection.  .  (See  Pleurisy,  Vol. 
II,  pp.  102,  113,  and  Lumbar  Puncture,  Vol.  II,  p.  235.) 

Mental  and  Nervous  Symptoms. — In  what  has  already  been  said 
incidental  reference  has  been  made  to  various  diseased  states  of  the  nerv- 
ous system.  What  follows  is  by  way  of  addition  or  recapitulation. 
Further  discussion  will  be  found  in  the  section  upon  Nervous  Diseases 
(Vol.  II,  p.  232). 

Various  forms  of  mental  defect  are  to  be  recognized..  The  mother 
often  wrongly  supposes  that  the  child's  failure  to  take  notice,  walk,  or 
talk  is  due  respectively  to  defective  sight  or  hearing,  paralysis  of  the  legs, 
or  tongue-tie.  To  determine  whether  failure  to  notice  obj  ects  at  the  proper 
age  is  due  to  idiocy  or  to  blindness  is  often  a  matter  of  difficulty.  An 
ophthalmoscopic  examination  may  settle  the  question.  Slowness  in  learn- 
ing to  speak,  when  not  dependent  upon  imbecility,  can  be  the  result  of 
defective  hearing  or  of  a  general  slowness  of  development  caused  by  ill- 
health.  Yet  often  it  seems  to  be  merely  a  peculiarity  of  the  individual, 
irrespective  of  other  conditions,  and  need  then  cause  no  anxiety.  A 
marked  tendency  to  allow  the  saliva  to  dribble  out  of  the  mouth  is  a 
characteristic  of  the  idiotic  state.  A  condition  of  confusional  insanity, 
almost  maniacal  at  times,  may  develop  after  fevers,  especially  typhoid. 
Simple  anger  becomes  so  uncontrollable  in  many  children  that  it  occa- 
sionally seems  almost  maniacal.  Delirium  is  a  frequent  attendant  of 
high  temperature  in  children,  and  does  not  necessarily  indicate  the 
presence  of  serious  disease.  It  may  occur  even  in  infancy,  although 
at  this  age  convulsions  tend  to  replace  it.  Convulsions,  indeed,  are  very 
prone  to  develop  in  early  life.  They  may  be  due  to  many  causes,  often 
of  the  most  trivial  nature.  Pneumonia  and  all  the  infectious  fevers, 
especially  scarlatina,  may  be  ushered  in  by  them,  and  even  high  tem- 
perature from  other  sources  is  likely  to  produce  them  in  some  subjects. 
Rickets  is  a  peculiarly  frequent  {)redisposing  cause.  Tiiey  may  result, 
too,  from  peripheral  irritation  of  various  sorts,  particularly  of  the  gastro- 
intestinal tract,  diseases  of  the  brain,  and  uremia.  Occurring  in  the  new 
born  they  are  frequently  the  sign  of  intra-cranial  trauma  or  disease. 


208  THE  DISEASES  OF  CHILDREN 

Hysteria  may  be  witnessed  even  in  early  childhood,  and  the  presence 
of  maUngering  dependent  upon  this  is  often  to  be  recognized.  In  fact, 
the  power  of  imagination  is  so  great  in  childhood  that  pains  are  very 
liable  to  be  complained  of  if  the  suggestion  of  pain  is  made  to  the  child. 
Aphasia  in  children  has  not  the  grave  import  or  the  diagnostic  value  of 
the  symptom  in  later  life.  It  sometimes  occurs  temporarily  after  typhoid 
fever. 

Psychic  and  nervous  symptoms  are  much  more  easily  evoked  in  early 
than  in  adult  life.  Great  restlessness  or  excessive  talking  during  sleep, 
somnambulism,  and  such  semi-delirious  states  as  are  seen  in  night-terrors 
illustrate  the  readiness  with  which  the  mental  condition  of  children  is 
affected  by  such  slight  causes  as  temporary  fever,  indigestion  and  over- 
exertion. Extreme  excitement,  with  crying,  may  be  due  to  disease  or 
may  be  dependent  only  upon  accidental  causes.  Great  irritability  is 
evidence  of  an  unhealthy  state.  Sometimes  it  maj^  be  merely  the  result 
of  indigestion  or  malaise,  but  in  other  instances  it  points  strongly  to  the 
beginning  of  meningitis  of  the  tuberculous  form.  Indifference  to  sur- 
rounding objects  and  the  ceasing  to  play  with  toys  indicates  a  serious 
affection  of  health.  It  may  depend  upon  great  weakness  or  upon  intra- 
cranial disorder.  Stuporous  and  comatose  states  with  the  attendant 
symptoms  occur  in  actual  organic  disease  of  the  brain,  or  may  be  the 
result  only  of  severe  functional  disturbance  of  it.  Thus  the  condition 
of  "  pseudo-hydrocephalus, "  very  closely  resembling  meningitis,  may 
develop  as  an  attendant  upon  great  weakness,  especially  after  severe 
diarrhea.  Absence  of  the  patellar  reflex  may  occur  in  poliomyelitis, 
the  muscular  dystrophies,  diphtheritic  and  other  neuritic  paralyses  and  in 
Friedreich's  ataxia.  Increase  of  the  knee-jerk  may  be  a  symptom  of 
cerebral  palsy.  Pott's  disease,  disseminated  sclerosis  and  of  some  forms  of 
cerebellar  disease,  or  may  be  without  serious  import. 


CHAPTER  X 

MORBIDITY  AND  MORTALITY 

TENDENCY  TO  DISEASE  IN  INFANCY  AND  CHILDHOOD 

The  greatest  tendency  to  disease  in  general  appears  to  exist  in  the  1  st 
year  of  hfe,  and  especially  in  the  new  born;  the  least  at  the  age  of  from  10 
to  15  years.  There  is  besides,  as  has  already  been  indicated  (p.  182),  a 
predisposition  to  certain  diseases  during  infancy  and  childhood  as  con- 
trasted with  adult  life,  and  a  comparative  freedom  from  others.  A  differ- 
ence exists,  too,  in  the  susceptibility  to  particular  diseases  at  the  various 
periods  of  early  life,  different  stages  of  development  being  attended  by 
different  maladies.  Thus  in  the  new  born  exists  a  group  of  affections, 
almost  characteristic,  which  are  due  either,  first,  to  disease  or  defects  of 
development  persisting  from  fetal  life,  or,  second,  to  injuries  or  disease 
arising  at  birth  or  very  shortly  after  it.  In  the  first  class  are  all  the  mal- 
formations and  congenital  disorders,  such  as  those  of  the  heart,  intestines 
and  brain,  as  also  the  different  forms  of  imperfect  development  visible  to 
the  eye,  and  the  inherited  affections,  especially  syphilis.  There  is  also 
the  state  of  congenital  asthenia  with  which  very  many  infants  appear  to 
})e  born  and  which  in  no  way  depends  necessarily  upon  premature  birth, 
although  a  common  result  of  this.  In  the  second  group  are  the  injuries 
occurring  at  birth,  which  result  from  parturition,  notably  the  forms 
of  paralysis  dependent  often  upon  meningeal  hemorrhage  or  direct  injury 
of  the  brain  or  nerves,  hemorrhage  into  some  of  the  other  visera,  the 
various  dislocations  and  fractures,  and  injuries  of  the  surface  of  the 
body,  such  as  cephalhematoma.  In  this  class,  too,  are  a  number  of  dis- 
eases which  are  largely  peculiar  to  the  new  born,  such  as  forms  of  septic 
infection,  atelectasis,  pyloric  stenosis,  certain  types  of  pneumonia, 
icterus,  ophthalmia  of  the  new  born,  etc. 

From  the  end  of  the  first  3  or  4  weeks  of  infancy,  up  to  the  end  of 
the  1st  year  of  life  the  prevailing  diseases  are  those  connected  with  the 
digestive  apparatus,  over  one-half  of  them  belonging  to  this  category 
and  being  the  result  in  most  instances  of  artificial  feeding.  The  nervous 
system  is  also  unusually  sensitive,  and  convulsive  disorders  are  prone 
to  occur.  The  general  feebleness  of  the  young  infant  and  its  deficient 
power  of  reaction  render  it  less  able  to  resist  cold,  excessive  heat,  and 
other  debilitating  influences.  It  is  particularly  in  this  year  that  children 
seem  to  fade  away  under  the  influence  of  torrid  weather.  Diseases  of 
the  respiratory  tract  are  very  common,  and  pneumonia  is  frociuent  and 
liable  to  be  of  the  catarrhal  form,  and  often  fatal.  Scurvy  is  seen  espe- 
cially at  this  time,  as  are  the  earlier  manifestations  of  rickets.  Afi'ections 
of  the  thymus  gland  are  to  be  noted.  Acute  infectious  diseases,  as  a 
class,  are  less  liable  to  occur,  with  the  exception  of  i)crtussis  and  the  septic 
inf(!ctions,  and  to  a  less  extent  measles.  Diseases  of  the  skin  arc  common, 
thrush  is  a  frequent  aff'ection,  and  tuberculosis  is  often  encountered, 
usually  in  the  form  of  a  general  tuberculous  infection.  Inflammation  of 
the  lymphatic  glands  begins  to  be  frequent,  especially  of  the  internal 
glands  at  this  age,  and  may  be  either  simple  or  tuixn-culous  in  nature. 
14  209 


210  THE  DISEASES  OF  CHILDREN 

The  2d  year  of  life  sees  the  respiratory  diseases  continuing  to  prevail, 
while  the  digestive  disorders,  though  still  frequent,  are,  on  the  whole,  less 
so,  and  less  fatal  in  their  results.  Convulsions  still  occur  veiy  readily 
from  the  slightest  causes.  Meningitis  is  common,  rachitis  extremely  so, 
and  pyelitis  often  seen.  Diseases  of  the  lymphatic  glands,  especially  in 
connection  with  other  disorders,  continue  to  occur  with  a  frequency 
characteristic  of  early  life.  Adenoid  growths  of  the  nasopharynx  and 
hypertrophy  of  the  tonsils  become  frequent.  In  this  period,  too,  the 
marked  disposition  to  the  occurrence  of  acute  infectious  fevers,  especially 
diphtheria,  begins  to  be  manifested.  Throughout  the  first  2  years  of 
life  acquired  affections  of  the  heart  are  uncommon  and  rheumatism  rare. 
Tuberculosis  shows  itself  as  tuberculous  peritonitis,  adenitis,  meningitis, 
in  the  form  of  tuberculous  bronchopneumonia,  and  very  often  as  a  wide- 
spread general  tuberculous  infection.  Typhoid  fever  is  relatively  much 
less  frequent  than  later,  and  its  symptoms  often  obscure. 

During  early  childhood;  i.e.  after  the  age  of  2  years  to  that  of  6  years, 
there  is  a  predisposition  to  certain  forms  of  digestive  disturbances,  particu- 
larly disorders  of  the  stomach  and  small  intestine.  Diarrhea  is  less 
troublesome  than  in  infancy.  Tonsillitis,  pharyngitis  and  various  forms 
of  stomatitis  increase  in  frequency.  Respiratory  affections  are  very 
common,  and  spasmodic  croup  becomes  one  of  the  terrors  of  the  house- 
hold. Rheumatism  and  acquired  affections  of  the  heart  begin  to  be  ob- 
served although  still  not  common.  The  tendency  to  the  acute  infectious 
diseases  appears  to  be  approaching  its  height.  Appendicitis,  rare  under 
the  age  of  2  or  3  years,  begins  to  be  frequent. 

In  later  childhood;  i.e.  after  the  age  of  6  years,  chorea  becomes  fre- 
quent and  rheumatism  and  diseases  of  the  heart  also.  Functional  neuroses 
dependent  upon  school-life  are  to  be  noted,  as  are  also  myopia,  scoliosis, 
headache,  anemia,  and  the  like.  The  infectious  diseases  continue  ex- 
tremely frequent.  Meningitis  is  of  common  occurrence,  and  various 
psychoses  appear  as  puberty  is  approached. 

Chronic  affections  of  the  kidney,  with  the  exception  of  pyelitis,  are 
infrequent  during  the  whole  of  infancy  and  childhood,  unless  as  a  result 
of  scarlet  fever.  Acute  nephritis  may  readily  attend  the  infectious 
diseases,  and  often  in  infancy  is  associated  with  severe  diarrheal  dis- 
turbances. Disease  of  the  bones  and  joints,  generally  of  a  tuberculous 
nature,  is  frequent  in  all  periods  of  early  life,  although  less  so  in  infancy 
than  in  childhood.  Disease  of  the  brain-substance  is  rare  except  when 
secondary  to  meningeal  disturbance,  and  that  of  the  spinal  cord, 
nerves,  and  muscles  likewise  so,  the  exceptions  being  poliomyelitis,  which 
is  common  in  infancy  and  early  childhood,  the  neuritis  following  diph- 
theria, the  transverse  myehtis  resulting  from  spinal  caries,  and  the  mus- 
cular dystrophies  and  certain  systemic  nervous  affections  which  are 
characteristic  of  childhood. 

FETAL  MORTALITY.     STILL  AND  PREMATURE  BIRTHS 

Fetal  mortality,  including  miscarriages  and  still-births,  shows  a  high 
percentage  of  the  total  number  of  conceptions.  Whitehead^  calculates 
the  proportion  of  miscarriages  to  pregnancies  as  1  : 7,  and  Priestly  ^ as  1 :  43^^. 
In  28  cities  of  the  United  States  in  1890^  the  number  of  still-births  bore 

1  Ref .  Ballantyne,  Disease  of  the  Fetus,  1892,  I,  8. 

2  Ballantyne,  loc.  cit. 

3  U.  S.  Census,  Vital  Statistics,  II,  142. 


MORTALITY  IN  INFANCY  AND  CHILDHOOD 


211 


to  the  number  of  children  born  aHve  a  ratio  of  62.65:1000;  i.e.  5.9%  of 
the  total  births  were  still-births.  An  estimate  of  the  European  states 
makes  the  still-births  3.79%  of  the  total  births  (Wappaus).^  Ruppin- 
gives  the  still-births  of  Prussia  during  25  years  as  3.69%  of  the  total 
births. 

Premature  birth  is  also  a  frequent  cause  of  death  during  infancy. 
This  might,  in  a  sense,  be  included  in  fetal  mortality,  since  death  finally 
occurs  because  the  organism  is  not  in  a  state  fully  prepared  for  life  out- 
side the  uterus.  The  Census  statistics  of  the  United  States  for  1890^ 
make  5.68%  of  all  the  deaths  under  1  year  dependent  upon  premature 
birth.  This  is  probably  below  the  actual  figures,  since  many  deaths 
attributed  to  inanition  and  similar  causes  might  properly  have  been  classi- 
fied with  those  resulting  from  premature  birth. 

MORTALITY  IN  INFANCY  AND  CHILDHOOD 

Death=rate  Especially  in  the  First  Year. — It  is  a  matter  of 
common  observation  that  the  younger  the  child  the  more  dangerous,  as 
a  rule,  is  any  disease  affecting  it.     The  exhaustive  studies  of  Eross'*  based 


H  sum 

HBI      BBII 

00 

■  ■■■■■■ 

90 

■  ■■  ■■■ 

■■      ■■■ 

RH 

■  ■■■■■■ 

BB   BBB 
BB   BSS 

II  nl 

ou 

■   ■■HBH 

70 

■1  ■■   ■■■ 

rj\ 

■1  ■■    ■■■ 

'A) 

Afl 

■1  BBBHaB 
■fl ■■   ■■■ 

4U 

9n 

on 

■1  ■■BBin 

tall 
in 

■KHBBHHaS 

SiiHBHIfl 

0 

0  10         21)        .30         40         50         00        70  years. 

Fig.  29. — Graphic   Chart   Representing   the    Number   of   Deaths   for    Different 
Years  for  Every  1000  Persons  of  Each  Age. 
The  figure  2.53  represents  the  number  of  still-births.     (Westergaard,    Die  Lehre  v.   d. 
Mortalildt.,   1901.     Ref.  Prausnilz,  in  Pfaundler  and  Schlossmann's  Handb.   der  Kinder- 
heilk.,  1906,  /,  1,  279.) 

on  the  vital  statistics  of  13  European  States  for  a  number  of  years,  showed 
that  an  average  of  18.33%  of  all  children  born  died  in  the  1st  year,  equal- 
ing 26.89%  of  the  total  mortality  for  all  ages.  Of  the  deaths  in  the  1st 
year,  more  occurred  on  the  1st  day  than  on  any  other.  Of  the  fatal  cases 
in  children  under  1  year,  31.86%  took  place  in  the  1st  month,  and  73.13% 
in  the  first  6  months.  Nearly  one-half  of  the  fatal  cases  of  the  1st  month 
were  in  the  1st  week.  Later  investigations  support  these  figures,  those 
by  Holt  and  Babbitt,^  showing  that  of  100  deaths  in  the  1st  year,  13 
occurred  on  the  1st  day,  22  in  the  1st  week,  28  in  the  first  2  weeks,  and 
33  in  the  1st  month.  All  this  shows  a  rapidly  decreasing  mortahty  in 
proportion  as  the  infant  grows  o\dov.     This  diminishing  mortahty,  with 

1  AUg.  Bevolkcningsstatistik,  1859.     livL  Pfoiffcr,  Gcrhardt's  Handb..  d.  Kinderkr., 
I,  551. 

» Schmidt '.s  Jalirbiichcr,  1902,  CCLXXIII,  233. 

^Loc.  cit.,  IV,  ()(J(j. 

«Zeitsch.  f.  Hvgione,  XIX,  371. 

ojourii.  Amer.  Med.  Assoc,  1915,  LXIV,  287. 


212  THE  DISEASES  OF  CHILDREN 

subsequent  increase  as  adult  life  advances,  is  illustrated  graphically  in 
the  accompanying  curve  (Fig.  29)  after  Westergaard.' 

The  statistics  of  the  United  States  for  the  census  year  ending  in  1890^ 
give  very  similar  results  regarding  the  high  mortality  of  the  1st  year.  A 
percentage  of  18.29  deaths  occurred  in  the  1st  year  of  every  100  born 
alive  in  the  Registration  area.^  During  6  years'  observation  in  this  area 
251,424  deaths  occurred  under  1  year,  a  percentage  of  29.71  of  the  total 
number  of  deaths  for  all  ages.  Of  these  deaths  in  the  1st  year  55.77% 
were  in  the  first  3  months,  18.19%  at  from  3  to  6  months,  14.35%  from  6 
to  9  months  and  11.62%  from  9  to  12  months. 

There  is  considerable  variation  in  the  mortality  rates  according  to 
geographical  distribution,  the  relative  number  dying  in  the  1st  year  in 
the  countries  studied  by  Eross  being  lowest  in  Ireland  (9.4%)  and  Swe- 
den (9.7%)  and  3  times  greater  in  Saxony  (28.1%)  and  Bavaria  (28.7%,). 
It  is  still  higher  in  Russia  (32.6%)  (Gundobin).'*  Johannessen's^  sta- 
tistics for  Norway  gave  a  mortality  of  9.8%. 

The  influence  of  crowding  and  had  hygiene  is  very  positive.  The 
infant-mortalit}^  is  higher  in  the  poorer  classes  and  is  constantly  greater 
in  cities  than  in  the  country.  Many  of  the  larger  cities  of  Europe  and 
America  have  shown  a  mortality  in  the  1st  year  of  from  20  to  30  per  cent, 
of  those  born  (Deutsch).^  The  mortality  is  nearly  always  greater  among 
illegitimate  children  as  a  class,  for  various  reasons  not  dependent  on  the 
innate  vitality  of  the  child.  Deaths  among  infants  in  Homes,  Asylums, 
and  Hospitals  are  extremely  numerous,  in  spite  of  all  efforts  to  prevent  this. 
In  some  of  the  poorly  managed  institutions  the  mortality  has  reached,  or 
even  exceeded,  90  per  cent.,  and  in  the  best  it  has  often  averaged  50  per 
cent,  or  60  per  cent.  The  death-rate  is,  however,  being  decidedly  reduced 
as  improved  methods  of  hygiene  and  diet  are  being  followed.  The  causes 
of  the  high  mortality  depend  partly  on  the  character  of  the  infants  in 
these  institutions,  partly  on  the  improper  care  given  in  some  of  them, 
partly  on  the  spread  of  disease  from  one  child  to  another,  and  largely 
on  a  general,  imperfectly  understood,  deleterious  influence  which  attends 
the  keeping  of  many  infants  together  in  one  place,  and  to  which  the  title 
"hospitalism"  is  often  applied. 

The  m^WQnceoi  artificial  feeding  on  mortality  in  the  1st  year  is  very 
striking.  Of  34,325  infants  under  one  year  dying  in  Berhn,  17.7  per  cent, 
were  wholly  or  partially  breast-fed,  and  82.3  per  cent,  entirely  artificially 
fed  (Eross).  Undoubtedly  the  feeding  was  in  most  instances  improp- 
erly managed.  The  statistics  for  Munich,  as  published  by  Frank^  gave 
very  similar  results:  85.22  per  cent,  of  8329  deaths  under  1  year  of  age 
being  in  artificially  fed  infants,  with  but  14.78  per  cent,  among  those 
breast-fed. 

The  influence  of  season  upon  the  mortality  is  decided.  Both  the 
coldest  and  hottest  seasons  of  the  year  are  attended  by  high  mortality, 

iDie  Lehre  von  der  Morbiditiit  und  Mortalitat,  1901.  Ref.  Prausnitz,  Pfaundler 
und  Schlossmann's  Handb.  der.  Kinderlicilk.,  1906,  I,  1,  279. 

■^Loc.  cil.,  I,  22. 

3  The  "Registration  area"  for  that  date  included  the  registered  states,  Massachu- 
setts, Connecticut,  New  Hampshire,  Vermont,  Rhode  Island,  New  York,  New  Jersey 
and  Delaware;  the  District  of  Columbia,  and  83  registration  cities  in  non-registration 
states 

*  iahrb.  f.  Kinderh.,  1898,  XLVIII,  368. 

5  Jahrb.  f.  Kinderh.,  1902,  LVI,  2.59. 

«Centralbl.  f.  Ivinderh.,  1903,  VIII,  269. 

"  Ref.  Jacobi  in  Gerhardt's  Handb.  der  Ivinderkrank.,  I,  319. 


MORTALITY  IN  INFANCY  AND  CHILDHOOD 


213 


especially  in  the  1st  year  of  life.  In  the  United  States  the  mortality 
under  the  age  of  5  years  is  very  much  the  greatest  in  the  hot  summer 
months.^  The  increase  of  infantile  mortality  during  the  hot  weather 
is  not  only  dependent  upon  the  deleterious  changes  which  more  readily 
take  place  in  the  milk  at  this  season,  but  to  a  considerable  extent  upon  the 
direct  influence  of  the  torrid  weather  upon  the  infant.  This  has  been 
carefully  demonstrated  by  Rietschel,-  Schereschewsky^  and  others. 
The  plotted  curve  shown  in  the  figure  (Fig.  30),  after  Rietschel,  is  of  the 
infantile  mortality  in  Munich  froin  digestive  diseases  compared  with  the 
air-temperature  in  centigrade.  A  partial  exception  to  the  fatal  effects  of 
hot  summer  weather  exists  in  the  1st  month  of  life,  greatly  debilitated 
children  being  often  favored  by  hot  weather. 


z  JL  ^M  nr  V  w  TIL  im  IS  x  m:  se 
Fig.  30. — Deaths  from  Digestive  Disorders  ix  Infants  in  Munich  kkom  1895  to  1904. 
The  interrupted  line  indicates  the  mean  air-temperature;  the  other  the  number  of  fatal 
cases  for  each  month.  It  is  to  be  noted  that  the  height  of  the  death-curve  occurs  about  4 
weeks  later  than  that  of  the  temperature-curve.  (Rietschel,  Ergebn.  d.  inner.  Med.  u. 
Kinderh.,  1910,  VI,  416.  Based  upon  statistics  of  Fiirst,  Vierteljahrschr.  f.  offenll.  Gesund- 
heilsflege,  1907,  XXXIX,  417.) 


Sex  exerts  some  influence.  In  12  states  of  Europe  55.59  per  cent, 
of  the  deaths  in  the  1st  year  were  among  males  and  44.41  per  cent,  among 
females  (Ercss).  In  the  6-years'  record  of  the  Registration  Area  of  the 
United  States'*  54.83  per  cent,  of  the  deaths  under  1  year  were  among  males 
and  45.17  per  cent,  among  females.  As,  however,  there  are  about  95 
females  borne  for  every  100  males,  the  death-rate  of  females  as  com- 
pared with  the  males  born  is  a  trifle  greater  than  the  figures  express. 

It  is  difficult  to  determine  the  influence  of  race  apart  from  attendant 
climatic,  hygienic,  and  similar  conditions.  In  the  United  States  the 
mortality  of  the  white  races  in  the  1st  year  is  greatest  in  the  Italians, 
Bohemians,  and  Hungarians.  Among  the  dark  races  of  the  Ignited 
States  (Negroes,  Chinese,  and  Indians),  the  mortality  in  the  1st  j'oar 
exceeds  greatly  that  of  the  white  iiifjints. 


'  XI  Rep.,  U.  S.  Census,  ISDO,  11.  (53. 

-  Erncl)nisse  dcr  inn.  Med.  u.  Fviiiderh.,  1901,  VI,  369. 

3  Arch,  of  Ped..  1913,  XXX,  91(i. 

*  Loc.  ciL,  IV,  GOO. 


214  THE  DISEASES  OF  CHILDREN 

Diminution  in  the  Death=rate. — A  very  interesting  question, 
especially  as  regards  infants,  is  whether  or  not  the  death-rate  has  dimin- 
ished in  recent  years  under  increased  knowledge  of  infantile  diseases, 
and  especially  of  those  of  the  digestive  apparatus.  There  appears  to  be 
good  reason  to  believe  that  a  lessened  mortality-rate  has  indeed  occurred. 
Rich^  in  a  comparison  of  the  statistics  of  the  United  States  Census  of 
1900  with  that  of  10  years  earlier,  pointed  out  that  the  infantile  death- 
rate  in  the  Registration-Area  had  decreased  from  20.58  per  cent,  per  100 
births  in  1890  to  16.54  per  cent,  in  1900;  and  that  while  the  death-rate  of 
children  from  1  to  5  years  of  age  in  New  York  City  in  1891  equalled  96 
per  1000  individuals  of  this  age,  in  1896  it  had  fallen  to  77.5  and  in  1900  to 
67  per  1000.  Further,  according  to  the  statistics  of  Baker^  the  death-rate 
in  infants  in  New  York  City,  which  was  289  per  1000  infants  living  in  1880, 
gradually  but  uninterruptedly  fell  to  134  in  1910.  This  history  of  a  falling 
death-rate  in  infancy  and  early  childhood  is  borne  out  by  the  experience  of 
many  other  cities  of  the  United  States,  the  varying  degree  depending 
largely  upon  the  amount  of  civic  and  professional  care  observed.  The 
Statistical  Report  of  the  New  York  Milk  Committee  upon  the  infantile 
mortality  for  150  cities  of  the  United  States  for  the  year  1916  showed  a 
mortality  for  the  1st  year  which  averaged  in  the  neighborhood  of  10 
per  cent,  or  slightly  less.  The  reduction  in  infantile  mortality  appears 
to  be  taking  place  especially  in  subjects  suffering  from  gastrointestinal 
diseases.  This  has  been  due  to  a  large  extent  to  the  improvement  in  the 
quality  of  the  milk  supplied  and  the  more  strict  supervision  maintained  in 
cities  during  the  summer  season,  and  to  a  better  knowledge  of  the  proper 
treatment  of  digestive  disturbances. 

Causes  of  Death  at  Different  Ages. — Among  the  most  frequent 
causes  of  death  in  the  1st  year  various  conditions  appeai'ing  to  indicate 
an  inborn  state  of  debility  occupy  one  of  the  most  prominent  places.  Of 
the  174,614  deaths  in  this  period  occurring  in  Ireland  during  10  years 
"Debility,  Atrophy,  Inanition"  headed  the  list  with  29,136  deaths,  or 
16.69  per  cent.  "Convulsions"  came  next  with  a  percentage  of  11.89 
(Langford  Symes).^  The  latter,  however,  and  to  some  extent  the  former, 
represent  terminal  diseases  or  methods  of  dying  rather  than  the  real  cause 
of  death.  The  mortality-statistics  of  Massachusetts  during  5  years 
(1892-1896)  made  diarrheal  diseases  responsible  for  29.49  per  cent,  of 
the  total  deaths  occurring  in  the  1st  year  of  life  (S.  W.  Abbott),*  and 
respiratory  diseases,  classified  as  "pneumonia"  and  "bronchitis,"  for 
11.97  per  cent.  The  deaths  attributed  to  "atrophy"  and  "debility," 
many  of  which  were  probably  the  results  of  gastrointestinal  disease, 
equalled  10  per  cent.  The  statistics  of  the  Registration  Area  of  the 
United  States  for  1913,  as  analyzed  by  Woodward^  made  diseases  of 
the  digestive  system  responsible  for  deaths  in  the  1st  year  of  life  in  27.12 
per  cent,  and  diseases  of  the  respiratory  system  in  15.85  per  cent.  Of 
the  latter  96  per  cent,  depended  upon  bronchitis  or  pneumonia. 

The  mortality  from  digestive  diseases  is  especially  large  in  cities. 
38.5  per  cent,  of  the  deaths  under  1  year  occurring  in  the  civic  popu- 
lation of  France  were  due  to  gastroenteritis  (Budin).^ 

1  Arch,  of  Ped..  1905,  XXII,  762. 

2  15th  Intern.  Cong,  of  Hygiene,  1912,  III,  3,  pt.  1,  139. 

3  Med.  Mag.,  1898,  June. 

*  Jour.  Mass.  Assoc,  Board  of  Health,  1898,  Dec. 
6  Amer.  Jour.  Obstet.,  1916,  LXXIII,  362. 
«  Ann.  med.  et  chir.  inf.,  1903,  VII,  181. 


MORTALITY  IN  INFANCY  AND  CHILDHOOD  215 

Of  the  chronic  infectious  diseases  syphiHs  is  more  fatal  in  the  1st 
year  than  at  any  other  time,  about  }-i  of  all  the  deaths  from  this  affection 
occurring  in  this  year.  Tuberculosis  is  as  common  a  cause  in  the  1st 
year  as  later. 

The  number  of  deaths  from  the  acute  infectious  fevers  is  generally 
less  than  later  in  infancy  and  childhood  owing  to  the  much  smaller  inci- 
dence. To  this,  however,  pertussis  and  erysipelas  form  exceptions,  both 
of  them  causing  more  deaths  in  the  1st  than  in  any  other  year.  The  mor- 
tality from  measles  is  also  high  at  that  period.  The  cases  of  the  other 
infectious  fevers,  although  much  fewer,  have  a  relatively  unfavorable 
prognosis. 

In  the  2d  year  the  mortality  is  much  less.  The  Massachusetts' 
statistics  (S.  W.  Abbott)  ^  for  5  years  gave  about  }y^  as  many  deaths  for  the 
2d  year  as  for  the  1st  year  of  life.  Gastrointestinal  diseases  and  res- 
piratory affections  are  the  most  prominent  causes,  the  latter  gradually 
growing  in  importance  and  the  former  lessening.  The  deaths  from 
gastrointestinal  affections  equalled  19.79  per  cent,  of  the  total  deaths 
between  1  and  2  years  of  age,  and  respiratory  diseases  (pneumonia  and 
bronchitis)  21.27  per  cent. 

Infectious  fevers,  particularly  scarlet  fever  and  diphtheria,  play  a 
more  important  part  in  this  year,  rubeola  being  about  as  frequent  a 
cause  of  death  as  before.  The  deaths  from  tuberculosis  in  various  forms 
are  numerous,  especially  from  general  tuberculosis  and  tuberculous 
meningitis.  Convulsions  still  remain  a  very  prominent  cause,  or,  rather, 
method,  of  death. 

In  earhj  childhood,  from  the  age  of  2  to  that  of  5  or  6  years,  deaths 
are  chiefly  due  to  the  infectious  fevers.  AccorcUng  to  the  XI  Census 
Report  of  the  United  States^  the  number  of  cases  dying  of  scarlet  fever 
from  the  age  of  1  to  5  years,  as  compared  with  the  total  deaths  at  all 
ages  from  this  disease,  equalled  66.87  per  cent.  The  corresponding 
percentage  for  measles  was  64.36  per  cent.,  for  diphtheria  and  croup 
64.09  per  cent,  and  for  pertussis  43.31  per  cent.  By  far  the  largest 
actual  number  of  deaths  from  these  diseases  was  due,  however,  to  diph- 
theria and  "croup,"  the  latter  being  without  doubt  generally  diphtheritic. 

Viewing  infancy  and  early  childhood  together  it  is  noticed  that  the 
mortality  for  different  diseases  reaches  its  maxinmm  at  different  seasons 
of  the  year.  A  general  average  irrespective  of  the  nature  of  the  diseases 
shows  the  proportion  of  deaths  in  children  to  be  greatest  in  the  cool 
season  of  the  year  (Uffelmann).^  In  some  regions,  however,  the  mor- 
tality is  much  higher  in  summer.  This  is  very  decided,  for  instance,  in 
the  United  States'*  for  children  under  5  vears  of  age.  The  nature  of  the 
disease,  however,  has  an  important  influence.  Thus  in  the  Metropolitan 
District  of  the  United  States  during  the  6-ycar  record  there  were  10.413 
deaths  from  diarrheal  diseases  in  July  against  only  553  in  Dcceml^er, 
while  from  respiratory  diseases  there  were  but  1921  deaths  in  August 
against  5102  in  January.  Sex  continues  to  exert  a  slight  influence  after 
the  1st  vear  to  the  end  of  early  childhood,  rather  more  males  than 
females  dying. 

In  later  childhood;  i.e.  from  tlie  age  of  5  or  6  years  to  that  of  10  or 
12  years  the  mortality  is  lower  than  at  any  other  period  of  life.     The 

1  LdC.  cit. 

2Pt.    IV.,    (■)()(). 

^Handl).  d.  IIvK-  <!('«  Kiiules,  1881,  85. 
*  U.  «.  Census,  1890,  II,  03  and  I.  19."). 


216 


THE  DISEASES  OF  CHILDREN 


principal  causes  of  death  at  this  time  are  the  acute  infectious  diseases, 
especially  diphtheria  and  scarlet  fever.  Respiratory  diseases  also  con- 
stitute a  very  common  cause;  diarrheal  diseases  much  less  often  so. 
Tuberculosis  is  still  a  frequent  factor,  showing  itself  often  as  tuberculous 
disease  of  the  bones,  lungs,  and  peritoneum;  as  well  as  of  the  meninges 
and  in  the  form  of  general  tuberculosis  as  before.  Diseases  of  the  heart 
now  become  a  more  prominent  cause  than  before.  The  relative  im- 
portance of  certain  of  the  diseases  affecting  early  life,  in  their  influence 
upon  the  death-rate,  is  well  shown  in  the  accompanying  table  given  by 
Veeder^  (Fig.  31)  based  upon  930,067  deaths  in  subjects  under  10  years 
of  age. 


DISEASK 
STTHILIS 

ooimrMioiff 
scARLEx  pemt 
KEtnNains 

BRONCHITIS 

MEASLES 

PERTOSSIB 


FNEUUONI* 
(lob&r  &  unde- 
fined) 
COSOENITAL  DE- 
BILITY 

BRONCHO-PjIEUlJO* 
PREMATURE  BIRTH 


PART  PLAVED  BY  CERTAIN  DISEASES 
n*.%  OP  TOTAL  DEATHS)  IH  THE 
MORTALITY  OP  INFANCY  KS^i^SSi?^ 
AND  CHILDREN  DNDEB  10  YBS.  OP 
■■  AOE.  BASED  ON  630.067 
DEATHS.  0.  3.  A.  REOISTRATIOB 
AREA  1910-1913. 


AOE  DISTRIBOTIOII 
OP  DEATHS. 


73,61« 
7.9^ 

26,878 
2.7% 

35,474 
S.8)£ 

Se,842 

1128,072 
13. 7« 


2  yra, 


1  yr. 


I 


:>;^v>::Am\mm\m\vv\\mvw^\\^ 


^ 


Fig.  31. — Relationship   of   Certain   Diseases  to   the    Mortality  of  Infants  and 

Children. 
(Veeder,  Arch,  of  Pediat.,  1917,  XXXIV,  322.) 

Sudden  Death. — Death  occurring  suddenly  and  unexpectedly  is 
not  infrequent,  especially  in  the  first  2  years  of  life,  but  the  cause  is 
often  very  obscure.  In  some  instances  the  child  has  appeared  in  perfect 
health;  in  others  the  death  occurred  during  some  debilitating  disease, 
yet  without  there  developing  any  reason  for  the  sudden  fatal  ending. 
Sometimes  there  had  been  some  easily  overlooked  symptoms,  which  would 
probably  have  made  the  diagnosis  possible  and  accounted  for  the  death 
had  a  physician  been  in  attendance.  In  some  cases  an  autopsy  reveals 
the  cause,  but  in  many  it  does  not.  The  feeble  resisting  power  of  infancy 
and  the  great  excitability  of  the  nervous  system  are  the  principal  reasons 
for  predisposition  to  sudden  death  at  this  age.  The  various  causes  have 
been  reviewed  by  Thiemich,^  Vipond,^  and  others.^ 

Conditions  affecting  the  respiration  are  generally  considered  as  hold- 
ing the  most  prominent  etiological  place.     Coryza  in  the  new  born  may 

1  Arch,  of  Pediat.,  1917,  XXIV,  322. 

2  Vierteljahrsch.  f.  gerichtl.  Med.,  1901,  XXI,  300. 

3  Montreal  Med.  Journ.,  1901,  XXX,  23. 

■»  See  also  article  by  the  Author,  Amer.  Med.,  1903,  V,  989. 


MORTALITY  IN  INFANCY  AND  CHILDHOOD  217 

rarely  be  the  cause  through  what  has  been  described  as  "aspiration  of 
the  tongue"  (Bouchut).^  By  the  violent  efforts  at  breathing  through  the 
mouth  the  tongue  is  drawn  backward  and  its  under  surface  and  tip  be- 
come pressed  against  the  hard  palate,  cutting  off  more  or  less  the  entrance 
of  air.  Death  in  the  same  way  is  stated  occasionally  to  occur  in  3'oung 
infants  with  pertussis.  Asphyxia  from  over-lying  probably  does  not 
happen  as  frequently  as  once  supposed.  Although  a  considerable 
number  of  infants  die  in  this  way,  most  of  the  cases  assigned  to  this 
category  probably  belong  elsewhere.  Enlargement  of  the  uvula  has  been 
designated  a  cause  of  fatal  closure  of  the  glottis,  but  the  occurrence  of  the 
accident  seems  doubtful.  Spasm  of  the  glottis  is  perhaps  one  of  the  most 
frequent  apparent  causes;  certainly  so  in  those  infants  who  had  seemed 
to  be  in  perfect  health.  This  laryngo-spasm  depends  on  the  very  great 
irritability  of  the  nervous  system  which,  although  oftenest  seen  in  de- 
bilitated, and  especially  rachitic  children,  exists  sometimes  quite  inde- 
pendently of  these  conditions  and  is  a  symptom  of  spasmophilia  (Vol.  II, 
pp.  249,  256)  and  probably  closely  associated  with  lymphatism  (p.  632). 
It  is  likely  that  many  cases  of  death  attributed  to  other  causes  in  reality 
depend  upon  this  state.  Thus  it  seems  likely  that  the  sudden  death 
assigned  to  enlarged  thymus  gland  is  not  in  fact  connected  with  this,  but 
with  the  lymphatism  of  which  the  thymus  enlargement  is  but  a  symptom. 
(See  Diseases  of  the  Thymus  Gland,  Vol.  II,  p.  520;  Lymphatic  Diathesis, 
Vol.  I,  p.  632.)  Whether  or  not  the  death  is  actually  due  to  laryngo-spasm 
or  depends  upon  sudden  cardiac  failure  is  still  an  open  question.  Perhaps 
each  factor  may  be  the  cause  in  different  cases. 

Central  respirator}'-  involvement,  or  what  seems  probably  such, 
sometimes  occurs  in  cases  presumably  with  the  neurotic  tendency  which 
might  in  other  instances  lead  to  laryngeal  spasm.  In  these  cases  the 
child  may  die  as  though  from  sudden  heart  failure.  In  other  instances 
respiration  becomes  more  and  more  rapid  without  other  symptoms  or 
discoverable  reason,  and  the  infant  dies  in  a  few  hours.  I  have  seen  this 
accident  occasionally.  The  cause  of  the  condition  is  entirely  obscure. 
A  rapidly  developing  bronchopneumonia,  especially  in  the  new  born, 
may  sometimes  kill  with  apparent  suddenness,  the  attendants  having 
noticed  no  symptoms. 

Sudden  death  in  atrophic  infants  is  of  comparatively  frequent  occur- 
rence. Thus  it  often  happens  that  an  infant  who  has  been  ill  for  days  or 
weeks  with  unchanged  evidences  of  debility  will  unexpectedly  be  found 
dead  in  bed  without  there  having  been  any  alteration  in  symptoms. 
This  is  common  also  in  cases  of  premature  birth,  autopsy  often  showing 
no  lesions  whatever.  Yet  in  many  of  these  cases,  the  cause  is  found 
to  have  been  atalectasis,  to  which  very  young  infants  in  a  debilitated 
state  are  greatly  disposed.  In  many  other  instances  of  atalectasis, 
however,  the  process  comes  on  much  more  gradually  and  with  evident 
symptoms.  In  some  cases  the  deaths  in  marantic  states  may  be  due  to 
the  depressing  effect  of  chilling  or  to  a  fall  of  body-temperature  without 
discoverable  cause. 

Death  with  hyperpyrexia  is  often  very  unexpected  in  chiUheii  who  have 
been  perfectly  well  oi-  only  slight!}'  ailing  but  a  few  hours  before.  This 
may  Ijc  seen  in  heat-stroke  in  infants,  in  maUgnant  eruptive  fevers,  acute 
sepsis,  and,  still  more  frequently,  in  pneumonia  in  early  life.  Karely 
sudden  fatal  asphj'xia  may  result  from  the  rupture  of  a  caseous 
bronchial  gland  or  of  a  retropharyngeal  abscess  into  the  respiratory  tract. 
'  Mai.  des  nouveau-n6s,  1885,  279. 


218  THE  DISEASES  OF  CHILDREN 

In  other  cases  it  is  due  to  pressure  of  intrathoracic  growths,  abscesses,  or 
enlarged  glands  upon  the  pneumogastric  nerve.  The  aspiration  of 
food  into  the  windpipe  after  vomiting  has  been  assigned  as  a  cause.  It 
probably  occurs  much  less  often  than  has  been  supposed,  and  only  in 
infants  so  weak  that  the  ability  to  cough  has  almost  disappeared.  In- 
stances of  asphyxia  from  the  entrance  of  ascarides  into  the  larynx 
have  been  reported,  but  in  most  of  these  it  is  probable  that  the  worms 
entered  the  respiratory  tract  after  death.  Edema  of  the  glottis  is  also 
an  occasional  cause. 

Sudden  death  from  heart-failure  is  not  infrequently  seen  in  con- 
valescence after  diphtheria.  It  may  also  occur  in  debilitated  states 
or  in  respiratory  diseases,  especiallj^  pleural  effusion,  as  a  result  of  too 
sudden  a  movement,  improper  position,  or  excitement.  The  same  sudden 
cessation  of  the  heart's  action  may  take  place  in  acute  nephritis  on 
account  of  the  strain  of  increased  arterial  tension.  Sudden  stopping 
of  the  heart  may  occur  in  chronic  valvular  disease  or  as  a  result  of 
distant  nervous  influences.  It  is  probable  that  the  sudden  death  which 
has  occasionally  followed  quick  movement  or  excitement  in  apparently 
healthy  children,  such,  for  instance,  as  the  tossing  of  the  child  into  the  air, 
or  which  has  occurred  after  exploratory  puncture  of  the  pleura,  the  giving 
of  a  hypodermic  injection,  or  the  administration  of  an  anesthetic,  has 
been  in  reality  caused  by  inhibition  of  the  heart's  action  in  subjects  with 
lymphatism.  Many  of  the  deaths  assigned  to  spasm  of  the  larynx  are 
very  possibly  the  result  of  this  sudden  stopping  of  the  heart. 

Gastrointestinal  affections  seldom  occasion  sudden  death  except 
indirectly.  A  number  of  cases  are  reported  where  it  appears  to  have 
been  induced  by  the  irritation  produced  by  large  numbers  of  ascarides  in 
the  intestine.     This  is  probably,  however,  of  very  rare  occurrence. 

Convulsions  are  a  very  common  cause  of  sudden  death  in  children 
already  ill  or  in  those  in  whom  no  disease  has  been  detected.  Nervous 
reflex  irritation  from  various  regions  of  the  body  may  be  responsible  for 
them.  Congenital  syphilis  is  a  not  infrequent  cause  of  sudden  death,  even 
in  infants  who  appear  perfectly  healthy  (Fournier).^  Various  mal- 
formations and  accidents  not  already  mentioned  may  also  produce  it, 
among  them  perforation  of  the  intestine,  entrance  of  foreign  bodies  into 
the  larynx  or  trachea,  injuries  from  forceps,  strangulated  hernia,  external 
hemorrhages  from  the  stomach  or  bowels,  and  internal  hemorrhages, 
especially  in  the  new  born,  into  the  suprarenal  bodies  and  occasionally 
into  the  brain  or  elsewhere. 

1  La  sem.  mod.,  1901,  XXI,  20. 


i 


CHAPTER  XI 
THE  THERAPEUTICS  OF  INFANCY  AND  CHILDHOOD 

Therapeutics  in  infancy  and  childhood  possesses  a  few  characteristics 
which  sometimes  render  the  subject  easier  and  more  satisfactory  than  in 
later  years.  All  the  tendencies  of  life  are  toward  recovery,  and  the 
system  generally  responds  well  to  remedial  measures.  Drugs  when 
given  should  be  in  sufficient  strength  to  do  good,  but  never  to  do  harm, 
and  they  should  not  be  administered  at  all  unless  distinctly  indicated. 
Under-dosing  is  futile;  over-dosing  harmful.  To  the  latter  there  exists 
a  widespread  tendency  among  physicians.  In  the  large  majority  of 
cases  little  medicine  of  any  sort  is  required,  and  the  careful  attention  to 
hygiene  and  diet  is  sufficient,  with  possibly  such  sUght  aiding  of  nature  as 
the  giving  of  a  laxative,  a  diuretic,  a  warm  bath,  rest  in  bed,  and  the  like. 

Despite  what  has  just  been  said  the  therapeutics  of  childhood  for  the 
most  part  presents  many  difficulties  to  the  inexperienced.  These  depend 
chiefly  on  the  fact  that  the  child  does  not  react  toward  remedial  measures 
merely  as  a  small-sized  man  would  do,  but  has  in  many  respects,  its 
own  susceptibilities.  Some  methods  of  treatment  influence  the  system 
more  powerfully  than  in  adult  life;  others,  useful  in  adults,  are  not  so 
in  childhood.  The  difficulty  in  giving  medicines  to  many  children  is 
another  factor.  Numerous  children,  as  a  result  of  whim,  or  of  the 
unpleasant  taste  or  smell  of  a  medicine,  refuse  this  altogether.  The 
administration  of  it  may  do  harm  through  the  struggling  which  arises, 
or  may  be  always  followed  by  vomiting.  The  taste  of  the  same 
medicine  may  be  not  at  all  disagreeable  to  another  child. 

The  therapeutics  of  early  life  is  thus  conveniently  divided  into  A, 
Administration  of  medicines  by  the  mouth.  B,  Treatment  other  than  by 
drugs  by  the  mouth.  The  order  of  consideration  by  no  means  indi- 
cates the  relation  of  their  importance,  but  rather  the  reverse  of  this. 
It  may  be  said  in  passing  that  the  older  method  of  measuring  by  apothe- 
caries weights  and  measures  will  be  chiefly  referred  to,  not  as  preferable, 
but  because  it  is  at  the  present  time  much  the  most  familiar,  and  because 
there  seems  to  be  no  practical  advantage  in  writing  prescriptions  in  the 
metric  system  and  ordering  the  administration  of  the  medicine  in  drops 
of  fluidrams.  Metric  equivalents  are  given  in  the  parenthesis  whenever 
this  seems  best.  A  fluidram  is  equivalent  to  jiractically  4  c.c,  a 
fluidounce  to  30  c.c,  a  grain  to  05.0  milligrams,  and  a  dram  (apothe- 
cary) by  weight  to  nearly  4  grams.  We  are  usually  obliged  in  family 
practice  to  regard  a  teaspoonful  as  equalling  1  fluidram  and  a  table- 
spoonful  as  the  equivalent  of  3^^  a  fluidounce;  although  the  great 
variation  in  the  size  of  teaspoons  and  tablespoons  renders  this  inaccurate. 
A  small  glass  graduate  should  always  be  rcconunendcd.  Locke'  gives  a 
teaspoonful  as  equalling  5  c.c.  and  the  tablespoonful  as  15  c.c. 

1  Food  Values,  lOlG,  24. 
219 


220 


THE  DISEASES  OF  CHILDREN 


A.  ADMINISTRATION  OF  MEDICINES  BY  THE  MOUTH 

1.  Method  of  Giving  Medicine. — In  this,  as  in  all  forms  of  medical 
treatment  in  early  life,  we  must  as  far  as  possible  avoid  the  occasioning 
of  fright,  pain,  or  great  excitement  of  any  sort.  Previous  good  training 
by  the  parents  will  have  rendered  the  administration  of  medicines  much 
easier.  The  physician,  on  his  part,  must  see  first,  that  the  doses  are 
small;  second,  that  the  taste  is  as  pleasant  as  it  can  be  made;  and  third, 
and  most  important,  that  the  giving  of  any  drug  is  really  necessary. 
There  is  no  question  that  children  are  often  much  over-dosed.  It 
is  often  impossible  to  conceal  a  disagreeable  taste.  In  such  an  event 
force  may  become  necessary  in  giving  the  dose.  Whether  this  shall  be 
employed,  or  whether  the  treatment  by  drugs  shall  be  foregone,  depends 
upon  the  needs  of  the  case.     Judgment  must  be  exercised,  remembering, 


Fig.  32. — Medicine-Dropper. 
Showing  the  correct  method  of  dropping  from  the  thicker  portion  of  the  tube. 


as  stated,  that  the  harm  from  the  fear  and  excitement  may  much  exceed 
the  good  which  the  medicine  might  do.  This  scarcely  applies  to  the  cases 
of  le.ss  severe  ailments  in  vigorous  children,  when  the  refusal  depends 
merely  on  ill-temper  or  obstinacy. 

Where  a  dose  of  medicine  has  to  be  administered  by  force,  the  child 
should  be  wrapped  as  for  the  examination  of  the  throat  (p.  187)  and 
held  by  an  attendant,  and  the  nostrils  compressed  for  a  moment.  Gen- 
erally the  mouth  opens  and  the  spoon  may  be  inserted  to  the  back! of 
the  tongue,  emptied,  and  slowly  withdrawn.  There  is  difficulty  in  swal- 
lowing if  the  spoon  is  not  removed  from  the  mouth.  In  infants,  the  press- 
ing of  the  chin  downward  and  backward  may  be  sufficient  to  open 
the  mouth.  Often  an  infant  who  spits  out  the  greater  part  of  a  tea- 
spoonful  of  medicine  will  take  it  very  well  if  it  is  given  in  divided  portions. 
It  may  well  be  administered  from  a  larger  spoon,  as  there  is  less  danger 
of  spilling  it  should  the  child  struggle. 

The  attendants  should  be  told  that,  in  cases  where  medicine  must  be 
given  it  is  better  to  waste  little  time  in  pleading  and  in  argument,  but  to 


ADMINISTRATION  OF  MEDICINE  BY  THE  MOUTH  221 

use  firmness  and  decision  from  the  very  beginning.  The  child  must  in 
no  case  be  deceived  regarding  the  character  of  the  medicine,  as  its  con- 
fidence is  lost  thereby,  and  the  giving  of  the  next  dose  will  be  only  the 
harder.  In  stuporous,  delirious,  or  greatly  exhausted  conditions  liquid 
medicine  may  be  administered  with  a  medicine  dropper  while  the  child  is 
on  its  back.  This  should  be  inserted  between  the  cheek  and  the  teeth 
to  prevent  its  being  bitten.  Nauseating  remedies  should  not  be  given 
upon  an  empty  stomach  when  this  can  be  avoided. 

In  the  ordering  of  quite  small  doses,  or  in  the  prescribing  of  powerful 
drugs,  the  physician  must  carefully  remember  the  difference  between 
the  minim  and  the  drop  of  many  solutions,  particularly  of  alcoholic  ones, 
such  as  tinctures;  and  that  the  size  of  the  drop  also  varies  with  the  mouth 
of  the  bottle  or  with  the  dropper  from  which  it  is  obtained.  Conse- 
fiuently  it  is  best  to  reckon  the  dose  in  minims  rather  than  drops.  Where 
the  attendants  are  to  measure  the  mixture  a  minim  glass  should  be  used, 
or,  if  drops  are  ordered,  the  nurse  should  be  told  exactly  the  method  of 
dropping  to  be  employed.  The  small,  sharply-pointed  medicine-droppers 
furnish  a  drop  scarcely  more  than  half  the  size  of  one  obtained  from  the 
edge  of  the  bottle-mouth.  A  curved  dropper  should  be  used,  and  the 
drop  should  fall  from  the  thicker  portion  (Fig.  32).  It  is  important,  too, 
to  recognize  the  differences  in  the  sizes  of  spoons,  which  make  it  safer  to 
have  the  "teaspoonful"  or  "tablespoonful"  prescribed  measured  as  a  dram 
or  a  half  ounce  in  an  accurately  graduated  medicine-glass.     (See  p.  219.) 

Unless  really  necessary  those  medicaments  should  not  be  used  which 
cause  unpleasant  secondary  effects,  sometimes  worse  than  the  disease 
itself.  Those,  too,  are  to  be  avoided,  when  possible,  which  are  almost 
uniformly  disliked  by  children;  and  the  individual  tastes  of  the  patient 
should  be  studied  as  well.  Much  can  be  done  to  disguise  unpleasant 
tastes  to  a  certain  extent.  As  a  rule,  infants  and  children  like  sweetened 
mixtures,  and  syrups,  saccharin  or  glycerine  may  be  used  for  sweetening. 
Among  the  serviceable  syrups  for  this  purpose  especially  for  older  children 
are  syrup  of  ginger,  syrup  of  raspberry  (rubus  idseus),  syrup  of  chocolate, 
syrup  of  orange-flower,  syrup  of  wild  cherry,  syrup  of  vanilla,  and  syrup 
of  lemon.  For  infants  the  simple  syrup  of  the  Pharmacopea  is  to  be 
preferred.  The  aromatic  waters  are  well-liked,  such  as  peppermint  water, 
spearmint  water,  cinnamon  water,  and  orange-flower  water.  For 
infants  spearmint  water  (aqua  menthae  viridis)  is  to  be  preferred  to 
peppermint  water  (aqua  mentha?  piperita^)  since  the  sharpness  of  the 
latter  is  often  unpleasant  and  occasions  choking  unless  well  diluted.  The 
elixir  aromaticus  and  the  elixir  glycyrrhizte  (elixir  adjuvans)  are  very 
serviceable  for  disguising  an  unpleasant  taste  in  the  case  of  older 
children.  It  must  nf)t  be  forgotten,  however,  tiiat  these  contain  about 
25  per  cent.,  of  alcohol  and  are  not  suitable  for  emj)loyment  in  full  strength 
in  the  case  of  young  subjects.  Bitter  medicines  are  generally  disliketl 
by  children,  but  infants  often  appear  to  find  them  not  unpleasant, 
especially  if  an  abundance  of  sweetening  is  added.  In  this  point  there 
is  the  greatest  individual  difference  seen.  In  some  instances  the  bitter 
taste  appears  to  make  the  infant -vomit  promptly.  Nearly  all  licfuid 
medicines  may  be  sweetened  and  diluted  with  water  when  given,  if  the 
••hild  finds  the  dose  as  prescribed  disagreeable.  Instruction  on  this  point 
should  be  included  in  the  directions  ui)on  the  label  on  the  bottle.  An 
exception  exists  where  sugar  may  disagree  with  the  digestion;  in  the  case 
of  oils  or  emulsions;  or  where  the  addition  of  water  makes  the  larger  bulk 
.still  more  difficult  of  administration. 


222  THE  DISEASES  OF  CHILDREN 

The  taking  of  a  sip  of  water,  milk,  or  orange  juice,  or  the  sucking  a 
mint  drop  or  chocolate  immediately  before  medicine  is  taken  dulls  the 
sense  of  taste  to  some  extent.  Another  sip  immediately  after  washes 
away  the  unpleasant  taste.  The  mother  should  be  instructed  that  the 
employment  of  sweets  in  this  way  is  to  be  confined  to  the  occasions  of 
giving  medicine.  Quinine  may  be  disguised  to  a  certain  extent  by  lico- 
rice, or  still  better  by  syrup  of  Yerba  santa  or  syrup  of  chocolate.  A 
nearly  tasteless  preparation  such  as  aristochin  may  replace  it  to  a  con- 
siderable extent.  Castor  oil  should  be  given  in  emulsion  with  an  aro- 
matic water;  floated  on  ice  water,  lemon  juice,  sarsaparilla  or  whiskey  and 
water,  or  stirred  in  hot  milk.  By  the  latter  method  it  is  rendered  nearly 
tasteless.  The  child  must,  of  course,  not  be  told  that  it  is  milk.  In  the 
case  of  infants  it  may  be  administered  warmed  in  the  spoon  to  make  it  less 
thick.  Many  infants  always  vomit  it,  and  to  these  it  should  not  be  given 
at  all.  Others  do  not  appear  to  dislike  it  in  the  least.  To  older  children 
it  is  generally  distasteful  unless  disguised.  Cod  liver  oil,  if  disguised,  is 
generally  liked  by  children.  It  is  best  given  as  an  emulsion  flavored  with 
mint,  or  combined  with  a  syrupy  malt-extract. 

Drugs  in  powdered  form,  if  comparatively  tasteless  and  small  in 
amount,  may  be  placed  directly  upon  the  tongue,  and  washed  down  with 
a  sip  of  water  or  milk.  It  is  still  better  to  have  them  combined  with 
sugar  when  prepared.  Powders  of  larger  size  may  be  mixed  with  a  tea- 
spoonful  of  jam,  preserves,  scraped  apple,  or  the  like,  if  there  is  no 
contra-indication.  Entirely  tasteless  powders  may  conveniently  be 
given  on  milk-toast  or  bread-and-milk  and  not  be  perceived  at  all. 

Little  children  cannot  take  pills.  Those  of  3  or  4  years  of  age,  if  well 
trained,  will  swallow  them  readily  if  thej^  are  small.  If  the  substance  is 
bitter  it  should  be  sugar  coated,  or  the  drug  enclosed  in  capsules.  The 
pill  may  be  conveniently  offered  in  a  small  portion  of  jam  or  of  preserved 
or  fresh  fruit.  The  rule  already  expressed  still  holds  good;  that  no  decep- 
tion is  allowable,  and  that  the  child  should  always  be  told  that  it  is 
"medicine." 

The  passage  of  drugs  to  the  infant  through  the  mother's  milk  has 
already  been  alluded  to  (p.  106).  For  practical  purposes  in  infantile 
medication  this  need  not  be  considered,  although  the  method  is  sometimes 
useful  for  the  treatment  of  the  fetus. 

2.  Dosage .^ — Various  posometric  tables  have  been  constructed  for 
use  in  childhood,  and  various  methods  proposed  for  the  calculation 
of  the  proportionate  doses  as  compared  with  those  of  adults.  No  fixed 
rule,  however,  can  be  entirely  accurate.  This  is  both  because  the  relative 
susceptibility  to  different  drugs  varies  greatly  at  this  time  of  life,  and 
because  one  cannot  be  guided  either  by  age  or  by  size  alone.  The  rule 
of  Clarke  makes  the  weight  of  the  child  the  numerator  and  150  pounds  the 
denominator,  the  resulting  fraction  being  the  portion  of  the  adult  dose  to 
be  employed.  However,  a  child  of  6  months  weighing  no  more  than  a 
child  of  1  month  may  need  a  decidedly  larger  dose  than  its  weight  would 
indicate.  The  rule  of  Young,  which  adds  12  to  the  age  and  divides  the 
age  by  the  result,  ignores  entirely  the  elements  of  size  and  weight.  In 
practice,  both  age  and  weight  must  be  considered.  For  the  average 
child,  Young's  rule  is  a  very  convenient  one  down  to  the  age  of  2  years. 
Earlier  than  this  the  dosage  may  be  based  partly  upon  the  age  and  partly 
upon  the  weight.  The  following  table  of  proportionate  dosage  is  the  one 
I  am  in  the  habit  of  employing  as  a  guide,  but  in  a  general  way  only. 


ADMINISTRATION  OF  MEDICINES  BY  THE  MOUTH  223 

Table  66. — Proportional  Doses 

Adult 1 

18  years %  + 

12  years }4 

8-10  years % 

6  years }i 

4  years J4 

3  years H 

2  years }^ 

1  year Ho 

9  months Ms  or  %  dose  for  1  year 

6  months Ko  or  J-^  dose  for  1  year 

Birth  to  3  months 3^0  or  }>i  dose  for  1  year 

3.  Effect  of  and  Susceptibility  to  Certain  Drugs. — Certain 
medicines  are  peculiarly  well  tolerated  and  of  much  value  in  early  life. 
Others  are  dangerous  except  in  amounts  smaller  than  the  proportionate 
dose  for  the  age  would  be.  The  dosage  in  general  will  be  found  in  the 
table  on  p.  229.     The  following  drugs  require  special  mention. 

Alcohol  in  the  form  of  wines  and  spirits  is  tolerated  in  relatively  large 
doses,  and  is  exceedingly  useful  in  many  conditions.  It  is  given  far  too 
frequently  and  freely  by  many  physicians,  and  in  absurdly  small  amounts 
by  others.  Judgment  is,  of  course,  required  in  deciding  upon  its  employ- 
ment and  upon  the  dosage.  It  is  indicated  in  many  conditions  where 
cardiac  failure  threatens,  as  in  bronchopneumonia  and  in  many  cases 
of  the  infectious  eruptive  fevers,  but  especially  in  diphtheria.  In  exhaus- 
tion from  any  cause  it  is  useful,  as  also  in  many  cases  of  shght  debility 
where  a  gently  stimulating  effect  is  sought.  It  should  not  be  given  in 
acute  febrile  conditions  of  short  duration  where  the  heart's  action  is 
strong  and  the  temperature  high.  It  is  not  needed  in  mild  cases  of 
typhoid  fever  or  pneumonia. 

Whiskey  is  the  fonii  oftenest  serviceable.  It  contains  about  40  to  45 
per  cent,  by  weight  of  alcohol.  Brandy  may  be  emploj'ed  in  equal  dose. 
Port  wine  is  excellent,  and  is  well  liked  by  many  children.  Its  dose  is 
somewhat  over  twice  that  of  whiskey.  Other  wines  are  not  so  often  of 
value  in  early  life  on  account  of  their  greater  bulk.  On  occasions,  how- 
ever, champagne  is  useful  for  older  children.  It  must  be  borne  in  mind 
that  many  of  the  liquid  beef  preparations  on  the  market  are  quite  strong 
in  alcohol,  although  their  nutritive  value  is  slight,  and  that  there  is  danger 
of  giving  them  in  excess.  They  are  often  excellent  as  stimulants,  as 
their  taste  is  pleasant.  The  dose  may  be  determined  by  comparing 
their  alcoholic  strength  (p.  167)  with  that  of  whiskey. 

The  amount  of  whiskey  to  be  given  varies  with  the  demands  of  the 
case.  An  average  dose  every  3  or  4  hours  up  to  the  age  of  3  months  would 
be  5  to  10  minims  (0.31  to  0.62).  This  may  be  readily  increased  during 
a  short  period  in  emergency.  The  dose  at  1  year  would  be  10  to  20  minims 
(0.62  to  1.23). 

Alcoholic  stimulants  should  be  given  well  diluted.  They  may  some- 
tinies  be  mixed  with  the  milk-food  of  the  infant;  but,  if  it  is  important 
to  insure  that  the  full  amount  be  taken,  it  is  better  to  give  them  with  a 
little  sweetened  water  from  a  spoon,  or  to  add  them  to  only  so  much  of  the 
food  as  is  certain  of  being  ingested. 

In  view  of  the  extensive  controversy  which  has  taken  place  with  regarti 
to  the  employment  of  alcohol  as  a  therapeutic  agent,  it  would  seem  to  be  a 
fair  statement  to  say  that  alcohol  is  a  drug,  which,  hke  all  other  dnigs  of 
power,  is  capable  of  doing  harm.     That  it  has  been  greatly  abused  and 


224  THE  DISEASES  OF  CHILDREN 

has  done  much  damage  in  the  past  through  the  too  free  administration  of 
it  by  physicians  is  beyond  question.  That  it  further  is  not  needed  in 
many  cases  where  it  formerly  was  given  unhesitatingly  is  equally  true. 
That  it  is  able  to  do  much  good  in  certain  conditions  seems  so  well  sup- 
ported by  the  clinical  experience  of  centuries  that  it  is  difficult  to  contro- 
vert this  by  the  apparent  results  of  physiological  experiments. 

Alkalies  are  well  borne  and  are  of  particular  service  in  early  life, 
on  account  of  their  power  to  neutralize  gastric  acidity  and  restrain  vomit- 
ing, and  for  other  reasons.  Liquor  calcis  in  teaspoonful  doses  may  be 
given  hourly  if  needed  in  early  infancy,  or  bicarbonate  of  soda  in  doses  of 
1  to  2  grains  (0.065  to  0.13)  in  the  first  months  of  life. 

Alkaline  salts,  such  as  the  citrate  of  potash  and  acetate  of  ammonia, 
are  much  employed  as  febrifuges.  Their  value  for  this  purpose  is  some- 
what uncertain.  1  to  2  grains  (0.065  to  0.13)  of  the  citrate  or  15  minims 
(0.92)  of  the  liquor  potassii  citratis  may  be  administered  every  3  hours 
at  the  age  of  1  year.  Very  much  larger  doses  are  needed  when  it  is  re- 
quired to  render  the  urine  distinctly  alkaline. 

Antimony  is  not  at  all  well  borne  in  infancy  and  early  childhood. 
Its  action  is  often  very  depressing,  whether  used  as  an  emetic  or  as  an 
expectorant.  Since  other  less  dangerous  drugs  readily  replace  it,  it 
should  not  be  employed.     It  is  mentioned  here  only  to  condemn  it. 

Antipyretic  drugs  of  the  coal-tar  series  are  in  my  experience  well 
tolerated  bj'-  children,  but  not  often  needed  to  reduce  fever,  external  meas- 
ures for  this  purpose  being  preferable.  They  are  serviceable,  however, 
when  such  measures  are  not  effective  or  well  borne  or  for  other  reasons' 
cannot  be  employed.  In  this  connection  a  warning  must  be  uttered 
against  the  effort  to  reduce  a  child's  temperature  merely  because  it  is 
elevated.  The  temperature  rises  from  very  slight  causes  in  early  life, 
and  runs  correspondingly  higher  than  in  adults.  Even  high  fever, 
unless  prolonged,  is  borne  remarkably  well  in  infancy  and  childhood. 
Unless  it  is  approaching  a  dangerous  hyperpyi'exia,  or  is  attended  by 
threatening  symptoms,  acute  elevation  of  temperature  generally  need 
cause  no  alarm.  When,  however,  very  prominent  nervous  symptoms 
attend  the  fever,  such  as  decided  delirium,  great  restlessness,  and  the 
evidence  of  impending  convulsions,  antipyresis  of  some  sort  is  required. 
It  is  particularly  in  these  conditions  that  the  coal-tar  antipyretics  do  good 
by  their  action  upon  the  nerve  centers.  Under  such  circumstances,  and 
if  hydrotherapy  has  been  ineffectual,  antipyrine  and  phenacetin  are  to 
be  depended  upon,  and  are  safe  in  proper  doses.  Acetanilid  is  more 
dangerous.  To  a  child  of  1  year  ^  to  1  grain  (0.032  to  0.065)  of  antipyrine 
or  phenacetin  may  be  given,  and  repeated  in  an  hour  if  necessary.  An 
amount  should  never  be  used  which  will  produce  a  rapid  and  very 
decided  fall  of  temperature  with  much  sweating,  since  the  danger  from 
antipyretics  lies  in  this  critical  fall. 

The  coal-tar  antipyretics  are  often  very  serviceable  in  controlfing 
nervous  symptoms  of  any  sort  even  in  the  absence  of  fever;  such,  for  in- 
stance, as  spasmodic  affections,  chorea,  asthma,  and  especially  pertussis. 
In  the  treatment  of  the  last-mentioned  antipyrin  is  one  of  the  best  of 
remedies.  For  the  control  of  this,  as  for  the  management  of  many  nerv- 
ous disorders,  the  dose  must  be  larger,  and  can  safely  be  made  so,  since 
there  is  no  danger  of  critical  fall  of  temperature.  An  infant  of  3  to  6 
months  may  receive  }i  grain  (0.016)  of  antipyrine  every  3  hours  for  an 
initial  dose,  and  one  of  1  year  1  grain  (0.065).  In  each  case  the  dose  may 
be  increased  two-  or  three-fold,  if  it  is  well  borne  and  necessity  demands  it. 


ADMINISTRATION  OF  MEDICINES  BY  THE  MOUTH  225 

Apomorphia  is  too  depressing  a  drug  to  be  used  in  infancy,  and  even  in 
childhood  it  may  well  be  replaced  by  other  expectorants. 

Aromatic  oils,  generally  in  the  form  of  aromatic  waters,  are  particularly 
useful,  well  tolerated,  and  agreeable.  Peppeimint  water  is  sometimes 
rather  strong  for  the  taste  in  the  first  few  months  of  life,  and  spearmint, 
fennel  (aqua  foeniculi),  or  cinnamon  water  is  then  to  be  preferred. 

Arsenic  is  borne  well  by  children.  Infants  of  a  year  may  take  \'i 
minim  (0.015)  and  even  up  to  2  minims  (0.123)  of  Fowler's  solution, 
well  diluted,  3  times  a  day,  if  found  to  agree.  In  later  childhood  the  dose 
is  often  as  large  as  or  larger  than  that  for  adult  life.  It  is  used  chiefly 
for  chorea,  syphilis,  and  in  some  forms  of  anemia,  and  has  been  recom- 
mended, too,  for  chronic  gastritis  in  infancy. 

Belladonna  is  borne  exceptionally  well  in  early  life.  One  minim  (0.062) 
of  the  tincture  (equivalent  to  about  3^^000  grain  (0.000021)  of  atropine), 
given  3  to  6  times  in  24  hours,  is  often  well  tolerated  in  the  1st  year  of 
life.  During  childhood  the  drug  is  often  borne  in  larger  doses  than  in 
adult  life.  Yet  the  individual  susceptibiUty  varies  extremely,  and  very 
small  amounts  often  flush  children  decidedly.  The  initial  dose  should, 
therefore,  always  be  small,  and  the  attendant  informed  of  the  possible 
result.  The  variation  in  the  strength  among  different  samples  of  the 
tincture  render  a  fresh  solution  of  the  alkaloid  preferable.  The  drug  is 
particularly  useful  in  enuresis  and  in  some  forms  of  bronchopneumonia. 

Bromides  are  tolerated  unusually  well,  and  are  of  great  service  in 
nervous  conditions,  especially  in  convulsions.  They  are  useful  also  for 
insomnia  and  colic.  A  child  of  2  years  requires  3  to  5  grains  (0.194 
to  0.324)  at  a  dose.  An  infant  up  to  the  age  of  3  months  takes  3^^  to  1 
grain  (0.032  to  0.065),  but  in  serious  conditions,  such  as  convulsions,  4  or 
5  grains  (0.259  to  0.324)  are  required,  either  by  the  mouth  or  be  enema. 

A  pustular  eruption  is  sometimes  soon  produced  by  the  use  of  the 
bromides.  In  my  own  experience  this  is  rare,  but  the  possibility  of  the 
occurrence  must  not  be  forgotten.     (See  Fig.  422,  Vol.  II,  p.  549.) 

Carbolic  acid  is  only  to  be  mentioned  on  account  of  the  caution  to  be 
used  in  even  its  local  application  in  infanc3^  Cases  of  poisoning  have 
repeatedly  occurred,  and  I  have  seen  severe  injury  to  the  skin  produced  by 
the  local  employment  of  some  of  the  proprietary  preparations  contain- 
ing the  drug.     It  is  better  to  avoid  it  unless  specially  indicated. 

Chloral  is  generally  borne  well  by  infants,  but,  as  it  is  a  powerful 
narcotic,  its  action  must  be  watched  carefully.  It  is  a  valuable  remedy 
in  severe  colic,  although  it  is  occasionally  irritating  to  the  stomach. 
Its  especial  place  is  in  the  treatment  of  convulsions.  The  dose  is  i/i 
to  3-2  grain  CO. 016  to  0.032)  for  milder  ailments  up  to  the  age  of  3  months. 
I'or  convulsions  at  this  age  1  to  2  grains  (0.065  to  0.13)  may  be  given 
1)V  the  rectum,  and  repeated  as  required. 

Cocaine  is  a  dangerous  remedy  in  early  life,  and  can  well  be  dispensed 
with.     It  is  mentioned  only  to  emphasize  this  fact. 

Cod  liver  oil  constitutes  one  of  the  very  best  of  the  tonic  remedies. 
Children  generally  take  and  digest  it  well.  From  \i  to  y^  fluidram  (0.92 
to  1.85)  in  emulsion  or  in  a  syrupy  malt-extract  should  be  given  to  ciiiklren 
iit  the  1st  year,  and  double  this  after  this  age.  It  should  not  be  adminis- 
tered wiicre  there  is  gastric  indigestion  especially  of  fat,  and  occasiouMlly 
it  is  not  well  tolerated  when  there  is  diarrhea.  ]^uring  very  hot  weather 
it  is  not  always  well  borne,  and  it  may  be  found  necessary  to  intermit 
its  administration  at  this  time.  Its  use  by  inunction,  while  possibly 
occasionally  of  benefit,  is  unpleasant  and  generally  unsatisfactory. 

15 


226  THE  DISEASES  OF  CHILDREN 

Digitalis  is,  in  my  experience,  a  useful  drug  in  infancy  and  childhood, 
and  generally  well  borne.  In  the  first  6  months  the  dose  of  the  tincture 
should  be  l-i  to  1  minmi  (0.015  to  0.062)  repeated  as  needed.  The  effect 
upon  the  pulse  must  always  be  watched  with  care,  and  the  drug  stopped 
if  irregularity  is  produced.  The  tendency  of  digitalis  to  disagree  with 
the  stomach  is  also  to  be  remembered.  The  relative  value  of  the  newer 
preparations  of  digitalis  is  still  under  discussion.  Digalen,  digipuratum 
digitalone,  digitalin,  and  others  are  well  spoken  of.  For  the  pres- 
ent my  preference  is  still  for  the  tincture,  except  for  hypodermic 
administration. 

Iron  is  a  very  useful  tonic  when  there  is  anemia.  It  is  not  needed 
in  other  conditions  with  debility.  To  infants  it  should  be  given  in  a  form 
as  unirritating  as  possible,  such  as  the  lactate,  citrate,  malate,  or  pyro- 
phosphate. For  older  children  Blaud's  pill  (pilulse  ferri  carbonatis); 
or  Vallet's  mass  (massa  ferri  carbonatis)  are  excellent.  Some  of  the  newer 
organic  compounds  on  the  market  are  very  serviceable,  but  appear  no 
better  than,  if  equal  to,  the  older  official  preparations.  The  possibility 
of  iron  producing  indigestion  is  not  to  be  forgotten. 

Ipecacuanha  is  generally  remarkably  well  tolerated.  A  child  of 
3  or  4  years,  or  even  younger,  can  ordinarily  take  as  much  as,  or  more  than, 
an  aduk.  As  an  expectorant  the  syrup  may  be  employed  in  doses  of  from 
3  to  4  minims  (0.185  to  0.246)  in  the  first  3  months,  and  6  to  8  minims 
(0.37  to  0.493)  at  1  3'ear,  every  2  or  3  hours.  Yet  individual  suscepti- 
bility exists,  and  the  mother  should  be  warned  of  the  possibility  of  vom- 
iting being  produced.  Ipecacuanha  is  one  of  the  most  serviceable  and 
least  depressing  of  emetics.  A  fluidram  (3.7)  of  the  syrup  may  be  given 
at  a  dose,  and  repeated  in  20  minutes  if  there  has  been  no  action. 

Mercury  in  nearly  all  forms  is  well  tolerated  by  children  and  seldom 
salivates.  For  its  constitutional  effect  in  infancy  it  is  conveniently  ap- 
plied in  the  form  of  the  ointment  or  the  oleate  smeared  on  the  binder.  In- 
ternally for  the  same  purpose  calomel  may  be  given  in  doses  of  }'i  to  3^ 
grain  (0.016  to  0.032)  or  gray  powder  in  doses  of  1  grain  (0.065)  or  even 
2  grains  (0.13)  3  times  a  day  to  infants  under  3  months.  The  bichloride 
of  mercury,  formerly  much  used  in  diphtheria,  was  surprisingly  well  toler- 
ated. An  amount  equaling  3-^2-gi'ain  (0.002)  every  2  hours  to  a  child  of  2 
years  was  a  common  dosage.  As  a  rule,  however,  the  milder  mercurials 
are  to  be  preferred.  Bichloride  of  mercury  used  locally  has  produced  toxic 
symptoms  in  infancy.  The  action  of  calomel  as  a  laxative  is  referred  to 
under  Purgatives. 

Nitro -glycerine  fills  a  valuable  place  in  the  therapeutics  of  infancy 
and  childhood.  It  is  tolerated  in  proportionately  very  large  amounts. 
3^:500  to  3^^oo  grain  (0.00013  to  0.0003)  by  the  mouth  or  hypodermically 
may  be  given  to  a  child  of  6  months,  repeated  soon,  and  frequently  in 
larger  dose.  It  is  often  of  great  value  where  there  is  failure  of  the  heart's 
force  in  various  diseases,  acting  probably  by  the  reduction  of  the  arterial 
pressure. 

Opiates. — In  the  first  2  or  3  months  of  life  opiates  must  be  given 
with  great  caution,  and  in  very  small  initial  dose  until  the  susceptibility  is 
ascertained.  At  any  period  of  early  life  instructions  should  always  be 
left  with  the  attendants  that  the  dose  is  to  be  lessened  or  the  medicine 
stopped  if  the  effect  has  been  decided.  In  greatly  debilitated  conditions, 
and  in  impending  coma  at  any  period  of  infancy,  opiates  are  liable  to  act 
with  unusual  power.  Except  under  these  circumstances,  the  suscepti- 
bility diminishes  after  the  age  of  3  months,  although  still  present  to  a 


ADMINISTRATION  OF  MEDICINES  BY  THE  MOUTH  227 

moderate  extent.  As  the  individual  reaction  varies  greatly,  after  the 
initial  tentative  dose  the  amount  can  be  increased  until  the  desired  effect 
is  produced.  Deodorized  tincture,  paregoric,  Dover's  powder,  morphine, 
heroin  and  codeine  are  perhaps  the  most  useful  preparations.  For  infants 
we  can  well  do  without  the  stronger  preparations  except  for  hypodermic 
medication.  The  average  initial  dose,  except  in  the  extremely  sensitive 
states  mentioned,  may  be  as  follows:  Up  to  the  age  of  3  months: 
Deodorized  tincture  )io  to  K5  minim  (0.002  to  0.004),  camphorated 
tincture  (paregoric)  1  minim  (0.062),  Dover's  powder  3^0  to  1.^0  grain 
(0.002  to  0.003),  morphine  and  heroin  1^00  to  Hoo  (0.00008  to  0.00013), 
codeine  3^^oo  to  3^^oo  grain  (0.0002  to  0.0003).  At  1  year  the  initial 
doses  may  be:  Deodorized  tincture  14  to  3^2  nainim  (0.015  to  0.031), 
camphorated  tincture  4  to  10  minims  (0.246  to  0.616),  Dover's  powder 
■^  to  ^-2  grain  (0.008  to  0.032),  morphine  and  heroin  3-^50  to  if  qo  grain 
(0.0004  to  0.0006),  codeine  H po  to  Ho  grain  (0.0006  to  0.0013).  Nothing 
that  has  been  said  militates  in  any  way  against  the  proper  employment 
of  opiates  when  needed.  At  any  period  of  life  they  constitute  in  many 
diseases  one  of  the  most  valuable  of  remedies,  and  the  physician  who 
through  unwarranted  fear  avoids  their  administration  to  infants  or  chil- 
dren is  separating  himself  from  one  of  the  most  useful  articles  of  the 
pharmacopea. 

Purgatives  are  generally  well  borne  by  children,  and  in  relatively 
larger  doses  than  in  later  life.  Calomel  is  one  of  those  most  frequently 
employed,  although,  in  my  opinion,  not  in  general  as  serviceable  as  cas- 
tor oil,  and  given  too  indiscriminately.  The  dose  is  proportionately 
much  larger  than  for  adults.  Up  to  the  age  of  3  months  1^4  to  3^12  grain 
(0.0027  to  0.0054)  may  be  given  hourly  until  }i  grain  (0.03''2)  is  taken  un- 
less an  effect  is  produced  sooner.  After  this  age  If  0  to  3^  grain  (0.0065 
to  0.008)  may  be  given  hourlj^  until  there  is  an  effect  upon  the  bowels[or 
until  1  grain  (0.065)  is  consumed. 

Castor  oil  is  a  deservedly  popular  purgative  in  infancy  and  child- 
hood. The  dose  is  proportionately  large.  Up  to  3  months  of  age  3^ 
fluidram  (1.85)  may  be  given,  and  1  fluidram  (3.7)  after  this  period. 
Should  it  tend  to  gripe,  the  addition  of  a  small  amount  of  deodorized 
tincture  of  opium  or  paregoric  is  serviceable.  An  old-time  favorite 
and  a  useful  mixture  consists  of  equal  parts  of  aromatic  syrup  of  rhubarb 
and  castor  oil.  Magnesia  is  also  a  serviceable  purgative.  IMagnesium 
oxide  (calcined  magnesia)  usually  agrees  well  with  the  stomach,  but  is 
unpleasant  to  take.  Children  of  a  year  may  have  from  5  to  20  grains 
(0.324  to  1.3)  or  more.  Magma  magnesise  (milk  of  magnesia),  which 
consists  merely  of  a  suspension  of  magnesium  hydroxide  in  water,  is 
almost  a  household  remedy.  Doses  of  from  ^2  to  1  fluidram  (1.85  to 
■3.7)  may  be  given  in  the  bottle  of  milk-mixture  in  the  case  of  infants 
artificially  fed.  Solution  of  citrate  of  magnesia  is  well  tolerated  and  often 
liked  by  older  chihh'cn,  particularly  if  it  is  not  too  acid  in  taste.  1  to  4 
fluidrams  (3.7  to  14.8)  or  more  is  the  dose  for  an  infant  of  1  year;  2  to 
4  fl.  oz.  (59  to  118)  at  the  age  of  2  to  4  years  or  older.  The  addition 
of  orange  juice  makes  it  agreeable  to  those  accustomed  to  this  fruit. 
Senna  in  the  form  of  the  syrup,  and  rhubarb  in  that  of  the  aromatic  syrup, 
are  each  useful  and  of  agreeable  taste.  Cascara  in  some  of  its  more 
pleasant  forms  is  very  serviceable  as  a  regulator  of  the  bowels,  alone  or 
combined  with  phenolphthalein. 

Pilocarpine  is  not  at  all  well  tolerated  by  infants,  and  should  not  be 
used.     It  is  liable  to  produce  dangerous  depression. 


228  THE  DISEASES  OF  CHILDREN 

Quinine  is  borne  in  exceptionally  large  amount.  It  may  be  given 
disguised  by  syrup  of  yerba  santa  or  syrup  of  chocolate  as  already  stated. 
Quinine  chocolates  also  are  often  useful,  although  less  trustworthy; 
and  aristochin  is  a  nearly  tasteless  form  of  quinine  and  is  often  effective. 
The  dose  of  sulphate  of  quinine  for  a  child  of  1  year  may  be  }4  to  1  grain 
(0.032  to  0.065)  3  times  a  day.  In  cases  of  malaria  larger  amounts  are 
generally  needed.  The  drug  may  be  given  in  the  form  of  suppositories 
in  double  the  dose  mentioned,  but  the  results  are  less  satisfactory. 

Salicylic  acid  and  its  compounds  are  well  tolerated,  except  for  their 
tendency  to  produce  vomiting. 

Strychnine  is  an  extremely  useful  drug  in  early  life.  It  may  be  given 
in  relatively  large  doses,  if  there  are  no  contra-indications.  It  is,  however, 
in  my  opinion,  often  administered  with  little  discrimination  where  other 
powerful  stimulants  are  more  serviceable.  It  is  quite  capable  of  pro- 
ducing or  increasing  in  children  a  state  of  nervous  excitability,  and  it 
should  be  avoided  whenever  such  a  condition  or  the  possibility  of  the 
occurrence  of  a  convulsion  is  present.  At  1  year  of  age  }ioo  to  i/fso 
grain  (0.0004  to  0.0006)  may  be  administered  daily  in  divided  doses,  but 
sometimes  larger  amounts  are  required.  Older  children  may  well  take  it 
in  the  form  of  minute  gelatin-covered  pills.  1  minim  (0.062)  of  tincture 
of  nux  vomica  contains  about  3^^oo  grain  (0.00016)  of  the  combined  alka- 
loids, chiefly  strychnine.  The  tincture  forms  one  of  the  best  of  tonics 
in  early  life. 

4.  Drugs  Grouped  According  to  Their  Action.- — The  following 
statements  may  be  made  in  addition  to  and  as  a  summary  of  what  has 
just  been  said,  grouping  the  drugs  together  according  to  their  action. 

(a)  Antipyretics. — ^In  cases  of  moderate  fever  the  alkaline  diuretics 
such  as  potassium  citrate  and  ammonium  acetate  are  very  commonly 
employed,  alone  or  combined  with  sweet  spirits  of  nitre.  The  actual 
value  of  these  drugs  in  reducing  fever  has  been  much  disputed.  In  all 
more  urgent  cases,  where  external  measures  cannot  be  employed  or  are 
unavailing,  the  coal-tar  derivatives  are  very  useful,  especially  if  nervous 
symptoms  are  present.  There  has  been  an  unwarranted  prejudice  against 
them.     Many  of  them  are  entirely  safe  if  properly  used. 

(6)  Astringents. — Bismuth  subcarbonate  is  probably  the  best  of  these, 
alone  or  in  combination  with  a  tannic  acid  preparation,  especially  such 
as  tannigen  or  tannalbin.  Full  doses  should  be  given,  as  they  are  harm- 
less. Opium  should  not  be  employed  except  when  fever  has  gone  and 
the  intestinal  peristalsis  is  too  active,  with  a  decided  loss  of  liquid  from 
the  bowel;  or  in  the  dysenteric  cases  where  there  is  excessive  straining. 

(c)  Purgatives. — These  are  given  under  the  same  conditions  as  in 
adult  life.  Castor  oil  is  perhaps  the  best  in  infancy,  or  milk  of  magnesia 
for  less  decided  action.  In  older  children  citrate  of  magnesia  is  one  of 
the  best  purgatives  when  taken  readily.  When  a  small  dose  is  required, 
sulphate  of  magnesia,  combined  with  rhubarb  or  senna,  is  efficacious; 
while  cascara,  phenolphthalein,  and  petrolatum  liquidum  are  among  the 
most  serviceable  regulators  of  the  action  of  the  bowels  when  a  tendency 
to  chronic  constipation  exists. 

(d)  Sedatives.— The  bromides  constitute  one  of  the  most  useful  and 
least  harmful  drugs  of  this  class  for  conditions  of  moderate  nervous  excita- 
bility, sleeplessness  and  the  like ;  and  are  frequently  serviceable  additions 
to  preparations  intended  to  relieve  ordinary  cough,  pertussis,  vesical 
irritability,  colic,  vomiting  in  infancy,  and  threatening  convulsions.  For 
the  actual  attack  of  convulsions  full  doses  are  required,  and  chloral  had 


ADMINISTRATION  OF  MEDICINES  BY  THE  MOUTH  229 

better  be  used  as  well.  Chloral  is  serviceable,  too,  in  cases  of  severe 
colic  in  infancy,  and  occasionally  in  very  decided  insomnia.  Antipyrine 
and  phenacetin  are  valuable  in  convulsive  conditions  of  any  sort,  and  in 
other  nervous  states;  especially  so  when  fever  is  also  present,  but  often, 
too,  during  apja'exia.  They  may  be  employed  with  advantage  to  relieve 
insomnia  and  headache,  and  neuralgic  pain  in  general  if  not  too  severe. 
Opium  should  be  reserved  for  cases  of  severe  pain  of  any  nature,  and  to 
relieve  harassing  cough.  It  is  of  value  in  pneumonia  when  cough  disturbs 
the  rest  too  greatly,  but  is  to  be  avoided  when  respiration  is  much 
interfered  with,  or  when  abdominal  distention  is  present.  It  finds  a 
useful  place  also  as  a  sedative  in  diseases  of  the  heart. 

(e)  Stimulants. — ^The  indications  and  contra-indications  have  already 
been  referred  to  (p.  223),  and  will  be  discussed  later  in  considering  the 
individual  diseases  in  which  they  may  be  employed.  When  a  rapid 
cardiac  stimulant  is  required,  as  in  threatened  cardiac  failure,  caffeine, 
camphor  and  adrenalin  given  hypodermically  are  to  be  selected.  Strych- 
nine is  much  employed  under  much  the  same  conditions,  but  is,  I  believe, 
of  less  value. 

(/)  Tonics. — Nux  vomica  is  probably  the  best  for  use  in  childhood, 
especially  in  cases  of  loss  of  appetite  and  in  persistent  debilitj-  from  any 
cause.  It  should  be  avoided  when  a  condition  of  nervous  excitability 
is  present.  Iron  is  useful  only  in  cases  of  anemia.  The  action  of  qui- 
nine as  a  tonic  is  very  variable.  In  some  children  it  works  well.  Cod 
liver  oil  is  one  of  the  best  of  tonics  for  chronic  states  of  debilitated  health 
and  poor  nutrition,  if  the  digestion  is  in  good  order. 

5.  Approximate  Average  Dosage  of  Different  Drugs. — From 
what  has  been  already  stated  the  impossibility  is  manifest  of  constructing 
a  table  of  doses  for  children  which  can  be  depended  upon  in  more  than  a 
general  way.  Every  medicine  must  be  tried  tentatively  with  every  child 
needing  it,  and  the  amount  to  be  given  must  vary  not  only  with  the 
susceptibility  but  with  the  necessity.  Urgent  cases  need  vigorous  treat- 
ment. The  following  table  of  approximate  dosage  for  a  child  of  1  year 
of  age  may,  however,  be  of  service  as  a  partial  guide.  The  doses  in  metric 
equivalents  are  enclosed  in  parentheses. 

Table  67. — Table  of  Dosage  at  the  Age  of  1  Year 

Acetanilid Vi-^i  gr.  (0 .  016-0 .  032) 

Aconite,  tincture H-Va,  m.  (0.008-0.016) 

Adrenalin  (1 :  1000  solution) 2-8  m.  (0 .  123-0 .  493) 

brandy 5-30  m.  (0.31-1.S6) 

champagne 1-3  dr.  (3 . 7-1 1.1) 

gin 10-60  ni.  (0 .  62-3 . 7) 

port  wine 10-60  ni.    (0.62-3.7) 

sherry 10-60  m.  (0.62-3.7) 

I  whiskey 5-30  m.  (0.31-1 .85) 

I  acetate,  liquor 15  ni.  (0.92) 

A^^,^ •         aromatic  spirits 2-5  m.  (0. 123-0.31) 

Ammonia   j  ..^..(.onate. Vi-l  ^r.  (0  032-0  065) 

1  cliloride 1-2  gr.  (0  Oli.")  -0 .  13) 

Antipyrine ^ K-l  Ki'-  (0  016-0.065) 

Arsenic,  Fowler's  solution 3'4-l  'i'-  (0  01.") -0.062) 

Asafetida,  milk 15-60  m.  (0 .  92-3 . 7) 

Atropine 3-2000-^000  Ki'-  (0  0000.32-0.000065) 

PeUadonna.  tincture H-2  m.  (0  031-0. 123) 

Benzoic  acid : y^-l  gr.  (0  032-0 .  065) 

f  salicylate 1-2  gr.  (0 .  065-0 .13) 

n;<=»r,„ti,      J  Kwl  carhonate 5-8  gr.  (0  324-0  518) 

liismuth  .    j  s„i,^.,iiif^te 2-4  gr.  (0 .  13-0  2.59) 

{  subnitrate 5-8  gr.  (0.324-0.518) 


Alcohol , 


230  THE  DISEASES  OF  CHILDREN 

Table  67. — Table  of  Dosage  at  the  Age  of  1  Year  (Continued) 

Brandy  (See  Alcohol) 

Bromides,  sodium  and  potassium 1-4  gr.  (0 .  65-0 .  259) 

Bromoform 1-2  m.  (0.062-0. 123) 

Caffeine  citrate J^-Ja  gr-  (0 .  016-0 .  032) 

Caffeine  sodio-benzoate  (hypodermically)  .  .  .  }'i-}'i  gr.  (0.016-0.032) 

Calcium  chloride 1-2  gr.  (0.065-0. 13) 

Calomel  (See  Mercury) 

Camphor  (hypodermically  in  oil) K-^i  gr.  (0.013-0. 032) 

Cascara,  fluid  extract 1-4  m.  (0 .  062-0 .  246) 

CastOf  oil 30-60  m.  (1.85-3.7) 

Chalk-mixture 15-60  m.  (0.92-3.7) 

Champagne  (See  Alcohol) 

Chloral  hydrate 3-^-2  gr.  (0.032-0. 13) 

Chloroform,  spirits _. 2  m.  (-0 .  123) 

Cinchona,  compound  tincture 5  m.  (-0.31) 

Cinnamon  water 30-60  m.  (1.85-3.7) 

Codeine  (See  Opium) 

Cod  liver  oil. 15-60  m.  (0.92-3.7) 

Corrosive  sublimate  (See  Mercury) 

Digitalis,  infusion 5-30  m.  (0 .  31-1 .  85) 

DigitaUs,  tincture ' ." 3^-2  m.  (0 .  015-0 .  123) 

Ergot,  fluid  extract 3-5  m.  (0. 185-0.31) 

Fennel  water 30-60  m.  (1 .85-3.7) 

Gin  (See  Alcohol) 

Ginger,  tincture 1-5  m.  (0.062-0.31) 

Heroin  (See  Opmm; 

Hexamethylenamine H'H  gr-  (0.016-0.032) 

Hydrochloric  acid,  dilute 1-2  m.  (0 . 062-0 .  123) 

Iodine  (See  Potash) 

[  powdered H-H  gi*.  (0 .  008-0 .  016) 

Ipecacuanha,  i  syrup 3-8  m.  (0 .  185-0 .  493) 

[  syrup  (As  emetic) 60  m.  (-3.7) 

'citrate K-1  gr.  (0.016-0.065) 

chl&ride,  tincture i^-l  m.  (0.031-0.062) 

iodide,  syrup 1-5  m.  (0.062-0.31) 

lactate i^-l  gr.  (0.016-0.065) 

pyrophosphate ^-1  gr.  (0 .  016-0 .  065) 

[  reduced M-H  gr.  (0.016-0.032) 

Kino,  tincture 5  m.  (0.31) 

I'Crameria,  tincture 5  m.  (0 .  31) 

Lactic  acid 5  m.  (0 .  31 ) 

Laudanum  (See  Opium) 

Lime-water H-2  dr.  (1 .85-7.4) 

Liquorice-powder 2-10  gr.  (0.13-0.65) 

f  citrate,  solution 1-4  dr.  (3 . 7-14 . 8) 

Ayro„r,a=,-o    J  inilk 1-2  dr.  (3.7-7.4) 

Magnesia      ^^-^^ 5_30  ^^    (0.324-1 .94) 

[.sulphate 3-10  gr.  (0.194-0.65) 

Manna 5-30  gr.  (0.324-1 .94) 

C  calomel M-1  gr.  (0.016-0.065) 

Tv/T«,.„„^„        calomel,  divided  doses  (as  purga- 

Mercury.  ^^^^^  ' ^    ^      K-1  gr.  (0.032-0.065) 

[  grey  powder 1-2  gr.  (0. 065-0. 13) 

Morphine  (See  Opium) 

Nitre,  sweet  spirits  of 2-6  m.(0. 123-0.370) 

Nux  vomica,  tincture 1-2  m.  (0. 062-0. 123) 

[codeine Vioq-Hq  gr.  (0.0006-0.0013) 

deodorized  tincture. M-3^  m.  (0.015-0.031) 

dover's  powder Vs-li  gr.  (0 ,  008-0 .  032) 

Opium  . .    \  heroin Kso-Moo  gr.  (0.0004-0.0006) 

laudanum '.  .  .    3^-K  m.  (0.008-0.031) 

morphine,  sulphate Kso-^foo  gr.  (0.0004-0.0006) 

paregoric  (camphorated  tincture)  3-10  m.  (0.185-0.62) 

Pancreatin 1-3  gr.  (0.065-0.194) 

Peppermint-water 30-60  m.  (1 .  85-3 . 7) 

Pepsin H-2  gr.  (0.032-0.13) 


Iron 


TREATMENT  OTHER  THAN  BY  DRUGS  BY  THE  MOUTH        231 

Table  67. — Table  of  Dosage  at  the  Age  of  1  Year  {Concluded) 

Phenacetin K-1  gr.  (0.016-0.065) 

Phenolphthalein >^-l  gr.  (0.032-0.065) 

Phosphorus 1-500  gr.  (0.00013) 

[citrate 1-2  gr.  (0.065-0.13) 

Potassium  \  chlorate 1  gr.  (0.065) 

[iodide K-1  gr.  (0.016-0.065) 

Quinine,  sulphate ^^^-1  gr.  (0.032-0.065) 

Rhubarb,  aromatic  syrup 15-30  m.  (0 .  92-1 .  85) 

Salicylic  acid  (See  Soda) 

Salol 1^-1  gr.  (0.032-0.065) 

Salophene i^-l  gr.  (0.032-0.065) 

Santonin M-><  gr.  (0.016-0.032) 

Senna K-4  gr.  (0.016-0.259) 

Senna,  svrup lS-30  m.  (0.92-1.85) 

Silver,  nitrate M20-J^o  gr.  (0.0005-0.001) 

f  bicarbonate 1-2  gr.  (0.065-0.13) 

Sodmm  phosphate 5-20  gr.  (0,324-1.3) 

bodmm  . .      salicylate }4-2  gr.  (0.032-0. 13) 

[sulphate .     3-10  (0.194-0.65) 

Spearmint-water 30-60  m.  (1 .  85-3 . 7) 

Squills,  syrup 3-10  m.  (0.185-0.62) 

Strophanthus,  tincture, %-2  m.  (0.015-0.123) 

Strychnine,  sulphate Moo-^-ioo  gr-  (0.00013-0.0003) 

Sulphuric  acid,  aromatic ^2-4  m.  (0,031-0.246) 

Tannic  acid 3^-4  gr.  (0.016-0.259) 

Tannigen 1-2  gr.  (0.065-0,13) 

Tannalbin 1-2  gr.  (0.065-0, 13) 

Terpene  hydrate V^^-H  gr.  (0.016-0.032) 

Trional 1-3  gr.  (0.065-0.194) 

Whiskey  (See  Alcohol) 

B.  TREATMENT  OTHER  THAN  BY  DRUGS  BY  THE  MOUTH 

1.  Hypodermic  Medication  by  Drugs. — This  holds  a  minor  place 
in  the  therapeutics  of  infancy  and  childhood  on  account  of  the  pain  and 
fright  which  attends  the  proceeding.  It  is,  however,  too  much  neglected, 
since  under  many  circumstances  it  is  invaluable;  as  w^hen  a  rapid  ab- 
sorption of  a  medicine  is  required,  where  the  rebellion  against  swallowing 
medicine  is  excessive,  or  where  it  is  important  that  the  stomach  be 
spared  as  far  as  possible.  In  cardiac  failure  medication  is  far  better 
given  in  this  way,  using  camphor  (1:10  in  olive  oil),  caffeine  sodio- 
benzoate,  preparations  of  digitalis,  strychnine,  nitroglycerine  and  adrena- 
lin. In  respiratory  failure  hypodermic  injections  of  atropine  are  largely 
employed.  Morphine  hypodermically  may  arrest  convulsions  or  exhaust- 
ing diarrhea.  As  in  the  case  of  adults  a  hypodermic  dose  should  be,  as 
a  rule,  considerably  less  than  that  given  by  the  mouth. 

2.  Hypodermoclysis. — The  injection  of  large  amounts  of  sterilized 
normal  saline  solution  (0.9  per  cent.)  under  the  skin,  is  invaluable  in  some 
states  of  exhaustion  or  where  there  has  been  great  loss  of  fluid  from  the 
tissues  as  a  result  of  diarrhea,  vomiting  or  hemorrhage.  Distilled  water 
should  be  employed  in  making  the  solution.  The  fluid  is  contained  in  a 
glass  funnel  or  in  a  bottle  or  other  vessel  with  an  opening  at  the  bottom 
(Fig.  ,33).  To  this  a  rubber  tube  is  attached  with  a  hypodermic  needle 
of  fairly  large  calibre  on  the  other  end.  All  shoukl  be  carefully  sterilized 
l)efore  using.  The  needle  may  be  introduced  into  any  region  with  abun- 
dant loose  areolar  tissue,  as  in  the  flank,  below  the  scajHihe,  or  the  lateral 
parts  of  the  abdomen.  The  fluid  shoukl  be  warmed  before  use  and  either 
only  a  small  amount  poured  into  the  vessel  at  a  time,  or  the  heat  main- 
tained by  the  application  of  warm  cloths  or  hot  water  ijags  about  the 


232 


THE  DISEASES  OF  CHILDREN 


vessel  (Fig.  35)  since  from  1  to  2  hours  may  be  required  to  allow  it  to 
enter  gradually  beneath  the  skin.  From  30  to  250  c.c.  (1  to  8.5  fl.  oz.)[in 
the  early  weeks  of  life  maj^  be  allowed  to  flow  by  gravity,  the  vessel  being 
suspended  about  2  feet  (61  cm.)  above  the  patient,  and  the  amount  given 
varying  with  the  weight  of  the  infant.  The  injection  may  be  made  once 
daily,  or  oftener  if  need  be.  Solutions  of  gelatin  have  been  given  in  a 
similar  manner  in  severe  cases  of  hemorrhage.  It  is  necessary,  however, 
to  obtain  absolute  sterilization  of  the  fluid,  or  severe  subcutaneous  suppu- 
ration may  occur.  A  simple  boiling  is  not  sufficient.  It  should  be  pre- 
pared in  an  autoclave.  A  solution  of  bicarbonate  of  soda  may  be  given 
by  hypodermoclysis  in  cases  of  severe   acidosis.     Inasmuch   as    it    is 


Fig.  33. — Apparatus  for  Hypodermoclysis. 
The  receptacle  may  be  covered  with  hot  cloths  if  necessary  to  maintain  the  heat. 


impossible  to  sterilize  this  without  transforming  the  bicarbonate  into  the 
irritating  carbonate,  the  solution  may  be  prepared  as  follows :  Bring  a  litre 
(333-^  fl.oz.)  of  distilled  water  to  the  boiling  point.  Remove  from  the 
flame.  Add  immediately  30  grains  (1.9)  of  sodium  bicarbonate  (C.  P.) 
taken  directly  from  the  original  container  and  weighed  in  a  sterilized 
vessel.  Cool  the  solution  to  a  temperature  of  110°F.  (43.3°C.)  and  use 
what  is  required  at  once.  Even  when  prepared  in  this  way  there  is  no 
certainty,  however,  that  it  will  not  prove  very  irritating,  and  it  is  better 
to  administer  the  solution  intravenously.     (See  p.  245.) 

3.  Intraperitoneal  Injections. — As  emphasized  by  Blackfan  and 
Maxcy,^  saline  solutions  may  often  be  advantageously  given  into  the 
peritoneal   cavity   instead   of   by   hypodermoclysis.     The   fluid   enters 

»Amer.  Jour.  Dis.  Child.,  1918,  XV,  19. 


TREATMENT  OTHER  THAN  BY  DRUGS  BY  THE  MOUTH        233 

rapidly,  and  from  100  to  250  c.c.  (3.38  to  8.45  fl.oz.)  can  be  introduced  in 
from  15  to  20  minutes.  The  skin  and  subcutaneous  tissue  are  picked  up 
between  the  thumb  and  finger,  and  the  injection  given  in  the  linea  alba 
just  below  the  umbilicus. 

4.  Suppositories  and  Enemata.^ — -These  constitute  a  useful  method 
of  giving  medicines.  Quinine  may  be  conveniently  administered  by 
suppository,  using  at  least  double  the  dose  by  the  mouth.  Suppositories 
of  gluten  or  of  glycerine  of  small  size  are  serviceable  for  the  relief  of 
constipation,  as  is  often  the  simple  soap-suppository  or  "soap-stick." 
Chloral  and  bromide  of  potash  are  to  be  administered  by  enema  in  cases 
of  convulsions,  but  the  size  of  the  injection  should  not  be  large  or  it  will 
not  be  retained.  From  1  to  3  oz.  (30  to  89)  is  sufficient.  The  enema 
is  conveniently  given  by  the  infant-syringe,  the  fluid  being  warmed 
slightly  and  injected  slowly.  After  the  injection  the  nates  must  be  kept 
pressed  together,  or  the  nurse's  thumb  held  over  the  anus  for  a  consider- 
able time,  to  prevent  the  expulsion  of  the  fluid.  Astringent  enemata  were 
formerly  much  employed,  as  of  tannic  acid  and  of  nitrate  of  silver.  Thej^ 
must  always  be  weak,  especially  the  latter,  or  irritation  and  straining  are 
produced.  About  3^^  grain  (0.008)  of  the  silver  salt  or  1  to  2  grains 
(0.065  to  0.13)  of  tannic  acid  to  1  ounce  (30)  of  water  are  sufficient,  and 
even  this  strength  is  not  always  well  tolerated.  The  injection  of  nitrate 
of  silver  should  be  followed  by  that  of  a  solution  of  common  salt.  Sus- 
pensions of  bismuth  are  frequently  serviceable  in  cases  of  irritation  of  the 
lower  intestinal  mucous  membrane,  using  1  dram  (3.9)  of  the  subcar- 
bonate  to  4  or  5  oz.  (118  or  148)  of  mucilage  of  acacia.  When  medicated 
enemata  are  to  be  employed  the  bowel  should  first  be  unloaded  by  an 
ordinary  enema.  For  this  purpose,  or  whenever  local  treatment  of 
constipation  is  desired,  a  small  injection  of  1  fluidram  (3.7)  of  glycerine, 
undiluted  or  mixed  with  from  1  to  2  oz.  (30  to  59)  of  water  often  suffices; 
or  a  larger  one  of  normal  salt-solution  or  of  soapy  water  may  be  given, 
allowing  the  child  to  receive  as  much  as  it  can  comfortably  hold.  When 
there  are  hardened  fecal  masses  present  an  enema  of  from  1  to  2  oz.  (30  to 
59)  or  more  of  warm  cotton-seed  oil  is  very  serviceable.  This  should  be 
retained  for  some  hours,  or  perhaps  over  night,  and  then  followed  by  an 
injection  of  soapy  water.  Nutrient  enemata  are  of  very  little  service  in 
infants,  as  they  are  seldom  retained  if  given  frequently  enough  to  be 
of  any  possible  service.  They  are  sometimes  of  value  in  older  children. 
The  administration  of  a  5  per  cent,  solution  of  glucose  in  this  way  has 
become  popular,  since  it  can  be  absorbed  from  the  large  intestine. 

5.  Irrigation  of  the  Intestine. — In  some  diseased  conditions 
thorough  irrigation  of  the  entire  colon  is  serviceable.  The  child  should  be 
laid  on  its  back  on  a  bed  or  table,  with  its  hips  slightly  elevated  and  its 
thighs  flexed  on  its  abdomen.  The  bed  should  be  protected  by  a  large 
rubber  sheet,  so  arranged  that  it  will  carry  off  the  water  into  a  receptacle 
beneath.  The  injection  should  be  given  from  a  fountain  syringe  or  glass 
funnel  and  tube  at  a  distance  of  about  2  feet  (61  cm.)  above  the  child. 
A  hard-rubber  nozzle  may  be  used,  a  small  roller-l)andage  being  wrapped 
about  this  to  act  as  a  plug  when  pressed  against  the  anus  (Fig.  34).  A 
nozzle  of  this  sort  allows  of  the  firm  pressing  of  the  nates  about  it,  in  order 
to  prevent  the  expelling  of  the  fluid.  There  is  no  advantage  ofl'ered  by 
the  employment  of  the  so-called  "high  injection;"  i.e.  the  inserting  of  an 
oiled  rubber-catheter  for  a  considerable  distance  into  the  bowel  and  the 
injection  of  the  fluid  from  a  fountain  .'syringe  through  this.  If  the  fluid 
of  the  injection  is  not  expelled  promptly,  there  is  only  one  other  direction 


234 


THE  DISEASES  OF  CHILDREN 


in  which  it  can  pass,   namely,   toward  the  cecum;  and  it  will  do  this 
whatever  method  of  administration  is  followed. 

The  injection  should  be  given  slowly  and  with  occasional  cutting  off 
of  the  water  by  squeezing  or  clamping  the  tube,  in  order  to  accustom  the 
bowel  to  the  pressure.  There  is  no  fear  of  over-distention  occurring,  if 
the  bag  of  the  syringe  is  not  too  greatly  elevated.  The  infant  will  now 
and  then  expel  the  fluid  with  force  at  the  sides  of  the  nozzle,  but  the 
injection  should  be  continued  until  a  gallon  (3785)  or  more  has  been  used, 
or  until  the  fluid  expelled  shows  little,  if  any,  fecal  matter.  The  colon 
will  hold  a  surprisingly  large  amount.  A  pint  (473)  may  be  introduced 
and  retained  without  distention  at  the  age  of  6  months,  and  1  to  2  pints 


Fig.  34. — Fountain-Syringe  fou  Intestinal  Irrigation. 
A  roller-bandage  wrapped  around  the  nozzle  checks  the  expulsion  of  the  liquid. 


(473  to  946)  or  more  at  the  age  of  2  years.  After  the  injection  is  com- 
pleted the  syringe  should  be  removed  and  the  Hquid  allowed  to  escape. 
If  a  catheter  has  been  employed,  it  may  well  be  detached  from  the  tube 
and  left  in  position  for  a  half  hour  or  more  until  all  the  water  has  been 
expelled,  as  a  portion  of  it  is  generally  retained  for  a  time. 

The  temperature  of  the  fluid  should  generally  be  about  95°  to  100°  F. 
(35°  to  37.8°C.)  or  somewhat  less.  In  some  instances  shghtly  cooler 
injections  of  75  to  90°F.  (23.9  to32.2°C.)  are  better,  as  where  severe  local 
inflammation  exists,  or  where  there  is  high  fever,  since  the  reduction  of 
the  body-temperature  can  be  accOmphshed  very  satisfactorily  in  this  way. 
Cool  injections  must  not  be  used  in  greatly  debilitated  infants  with  low 
body-temperature  or  where  collapse  is  impending.  The  fluid  employed 
for  irrigation  may  be  simply  water,  or  better,  a  normal  salt-solution 
(0.9  per  cent.)  or  about  1  teaspoonful  to  the  pint.  Where  there  is 
much  local  inflammation  irrigation  with  starch  water  (1  teaspoonful 
to  the  pint,  boiled)  is  often  very  serviceable.     If  the  starch  water  is  too 


TREATMENT  OTHER  THAN  BY  DRUGS  BY  THE  MOUTH  '     235 

thick  or  grows  too  ceol  while  passing  through  the  tube,  it  may  jelly  and 
cease  flowing.     Weak  antiseptic  solutions  are  also  recommended. 

6.  Enteroclysis. — In  some  cases  of  wasting  disease  or  of  collapse 
a  pint  (473)  or  more  of  warm  normal  salt-solution  may  be  introduced  and 
allowed  to  remain  (enteroclysis),  the  syringe  being  removed  and 
the  nates  pressed  together,  the  purpose  now  being  to  have  as  much  as 
possible  absorbed  into  the  general  circulation.  A  favorite  plan  is  the 
"drop-method"  (Fig.  35),  in  which  the  catheter  is  allowed  to  remain  in 
place  for  some  hours,  with  the  fluid  made  to  leave  it  in  the  form  of  drops 
at  the  rate  of  about  20  per  minute. 


Fig.  35. — Ai  r\i:vri  .^  iitii  THE  Drop-Method  (jf  E.vteroclysis. 
The  rapidity  of  the  flow  id  controlled  by  a  .screw-clamp.     Hot  water-bags  surround  the 
vessel  containing  the  liquid,     (a)  Larger  view  of  the  dropper- apparatus. 


7.  Inhalations.— Inhalations  of  vapor  constitute  a  most  useful 
plan  of  treatment  in  early  life.  The  inhalation  may  be  of  water-vapor 
alone  or  of  chemical  substances  in  the  form  of  a  vapor  or  spray.  For 
the  giving  of  a  spray  the  steam  atomizer  is  very  serviceable.  The  small 
glass  vessel  in  front  of  the  boiler  may  be  filled  with  water  or  hme  water, 
or  with  solutions  containing  benzoin,  small  amounts  of  turpentine,  or 
other  substance  as  de.sired.  The  spray  is  best  given  under  a  croup  tent, 
and  should  not  be  allowed  to  play  directly  against  the  face. 

A  sniall  room  may  be  filled  with  water-vapor  by  repeatetlly  plunging 
red-hot  iron— such  as  flat-irons,  stove  hds  and  the  like — or  hot  bricks  or 


236 


THE  DISEASES  OF  CHILDREN 


stones  into  tubs  containing  only  small  amounts  of  water.  The  slaking 
of  lime  in  the  room  is  an  efficient  old-time  method  for  accomphshing 
the  same  purpose.  It  is  impossible,  however,  to  keep  a  large  room  satis- 
factorily filled  with  steam  in  this  way,  and  the  use  of  a  croup  tent  around 
the  child  is  stronglj^  to  be  recommended  (Fig.  36).  This  may  be  im- 
provised by  placing  a  large  opened  umbrella  over  the  patient  and  draping 
blankets  over  this.  A  better  plan  is  to  fasten  poles,  such  as  broom 
handles,  upright  at  each  corner  of  the  crib,  and  to  connect  the  tops  of 
these  by  cord.  Blankets  may  now  be  thrown  over  the  framework  thus 
constructed,  so  that  they  fall  down  well  about  it.     An  "A"  shaped 


Fig.  36. — Croup-Tent. 
Steam-atomizer  on  the  table. 


opening  is  left  near  the  head  of  the  patient,  and  through  this  the  vapor 
from  a  croup  kettle  (Fig.  37)  is  conducted.  The  end  of  the  spout 
should  be  close  to  or  just  within  the  door  of  the  tent,  but  not  close  enough 
to  give  too  great  heat  or  to  permit  the  child  to  strike  it.  The  croup 
kettle  is  sold  provided  with  an  alcohol  lamp,  and  many  accidents  have 
occurred  through  this  catching  fire,  or  from  the  covers  of  the  croup 
tent  coming  in  contact  with  it  when  these  have  been  made  of  inflammable 
material.  On  this  account  sheets  should  not  be  used  to  form  the  covering, 
and,  when  possible,  the  croup-kettle  should  be  heated  by  a  small  gas 
stove  or  electric  stove  instead  of  by  burning  alcohol. 

Volatile  substances  such  as  benzoin,  turpentine,  eucalyptus,  etc.,  may 
be  added  to  the  water  in  the  kettle  before  the  lamp  is  lighted;  or  a  small 
sponge  may  be  saturated  with  them  and  placed  in  the  enlargement  of 


TREATMENT  OTHER  THAX  BY  DRUGS  BY  THE  MOUTH        237 

the  spout.     Carbolic  acid  should  be  avoided,  and  creosote  used  with 
caution  in  the  case  of  infants  and  young  children. 

Certain  drugs  may  be  given  in  volatile  form  without  the  use  of  water. 
Thus  calomel  may  be  volatilized  by  pouring  it  upon  a  piece  of  iron  heated 
by  a  flame. 


Fig.  37. — Croup-Kettle. 


8.  Inunctions. — Apart  from  the  use  of  ointments  for  the  local 
treatment  of  cutaneous  affections,  the  rubbing  with  oil}'  substances 
is  sometimes  employed  to  produce  general  absorption  of  the  drug. 
Mercury  is  conveniently  given  in  this  way,  a  small  amount  of  the  official 
ointment  being  rubbed  into  the  axillae  or  groins.  A  favorite  plan  in  the 
case  of  infants  is  to  apply  it  over  the  abdomen  on  a  flannel  binder. 
Salicyhc  acid,  especially  in  the  form  of  salicylate  of  methyl,  is  readil}' 
absorbed  by  the  skin.  Cod  liver  oil  has  been  much  used  by  inunction. 
Its  odor  is  extremely  unpleasant  when  employed  in  this  manner  and  it  is 
questionable   whether  it  offers  any   advantage  over  other  oils. 

9.  Applications  to  the  Nose  and  Throat. — Gargles  cannot  gen- 
erally be  used  before  the  age  of  6  or  7  years,  as  the  child  is  liable  to  swallow 
or  reject  them.  Painting  the  throat  and  nose  evokes  resistance  in 
nearly  all  cases,  but  is  sometimes  imperative,  and  is  often  easier  than  the 
use  of  the  spray.  The  method  of  procedure  has  already  been  given  in 
describing  the  examination  of  the  throat. 

Substances  should  be  selected  which  do  no  harm  if  swallowed. 
The  application  should  be  made  quickly  but  effectively.  This  may 
1)6  done  by  means  of  a  large  camcl's-hair  brush  mounted  on  a  stick,  or, 
better,  cotton  wrapped  firmly  upon  a  stout  aluminium  applicator. 
Painting  the  mucous  momliranc  of  the  nose  with  medicated  petrolatum 
is  often  very  serviceable,  and  is  usually  a  much  easier  method  of  treat- 
ment than  the  use  of  the  atomizer  unless  the  patient  is  docile.  A  small 
camel's-hair  brush  is  required,  and  the  procedure  should  be  verj''  gently 
carried  out.  In  the  case  of  infants  the  patient  may  be  placed  on  its 
back  upon  the  knees  of  the  nurse,  with  its  head  hanging  somewhat  down- 
ward, and  liquid  petrolatum,  medicated  if  desired,  may  be  droppetl  into 


238  THE  DISEASES  OF  CHILDREN 

each  nostril  with  a  bkint-tipped  medicine-dropper.     In  this  position 
gravity  takes  the  fluid  to  the  upper  part  of  the  nostrils. 

The  hand  atomizer  may  be  employed  for  spraying  the  nose  or  throat. 
For  oily  solutions  an  apparatus  should  be  chosen  which  gives  a  strong 
spray  in  a  short  time  and  without  too  much  labor.  Some  are  very  un- 
satisfactor5\  Liquid  petrolatum,  medicated  in  various  ways  as  by 
camphor,  menthol,  etc.,  is  much  used.  Aqueous  sprays  are  serviceable 
for  cleansing.  For  this  purpose  liquor  sodii  boratis  compositus  (Dobell's 
solution)  or  other  weak  alkaline-aromatic  solution  is  serviceable.  Per- 
oxide of  hydrogen  is  also  much  used.  A  preparation  of  this  should  be 
selected  which  is  not  acid,  and  the  dilution  should  be  at  least  1  :4  for 
treatment  of  the  nose. 

Syringing  the  nose  is  sometimes  required.     For  this  purpose  the  best 

syringe  is  one  entirely  of  soft  rubber  (Fig.  38)  holding  about  13>^  fl.  oz.  (44), 

or  a  fountain  syringe  may  be  employed  with  a  soft  rub- 

^^%  ber  nozzle.     The  child  when  debilitated  should  lie  upon 

ft  M  the  side,  the  syringe  being  applied  to  the  upper  nostril 

^:  J  and  the  injection  continued  until  the  liquid  comes  clear 

/^^^^         from   the  lower  nostril.     The  head  and  body  are  then 

^^^      ^^       turned  to  the  other  side,  and  the  syringing  done  through 

^^         ^,      the  second  nostril.     The  pressure  of  the  water  should 

j^g  ^i     always  be  low,  lest  material  be  forced  into  the  Eustachian 

^B  ^    tube  and  middle  ear.     In  cases  where  the  child  is  strong 

^§  ^    it  may  be  allowed  to  sit,  having  the  head  a  little  forward. 

^^,      _^^  Syringing  the  throat  is  carried  out  in  much  the  same 

^^^^^^^     ^vay,  the  child  sitting  upright  or  lying  upon  the  side. 

In  the  case  of  either  the  nose  or  throat,  only  mild,  harm- 

TippED^SoFT^RuB-  ^^^^  solutlous  shoukl  be  employed,  such  as  normal  salt- 

BER  Syringe  for  Solution  or  a  weak  one  of  boric  acid. 

Nasal  Douching.         Insufflation  of  medicine  in  powdered  form  upon  the 

mucous  membrane  of  the  nose  and  pharynx  finds  some 

place  in  the  therapeutics  .  of  children,    especially  in  such  diseases  as 

pertussis  and    diphtheria.     The    powcler   may    be    blown   in   with   an 

insufflator.     The    application  of   drugs    in   this  way  to   the  larynx  of 

infants  and  young  children  is  in  my  experience  difficult  and  unsatisfactory; 

certainly    requires   special   training   or   skill,    and  is  liable  to  produce 

severe  laryngeal  spasm. 

10.  Counter=irritants.- — ^Treatment  of  this  sort  is  particularly 
valuable  in  children.  The  delicacy  of  the  skin  in  most  cases  is  such  that 
care  must  be  taken  to  avoid  too  great  irritation. 

Blisters  are  not  suitable  for  infants  and  not  without  danger  of  serious 
injury  to  the  skin  even  in  childhood. 

Mustard  plasters  or  poultices  are  very  serviceable  in  such  conditions 
as  bronchitis.  They  should  be  made  of  mustard  with  flour  or  flaxseed 
meal  in  proportions  depending  upon  the  age.  In  infancy  a  strength  of  1 
of  mustard  to  5  or  6  of  flour  is  sufficient.  For  older  children  1  of  mustard 
to  3  or  4  of  flour  will  answer.  The  mustard  and  flour  are  mixed  dry 
and  then  stirred  with  hot  water.  The  paste  is  then  spread  between  two 
layers  of  thin  muslin  or  linen  and  applied.  The  poultice  is  left  on  a 
sufficient  time  to  redden  the  skin  thoroughly,  yet  not  long  enough  to 
blister.  The  time  varies  with  the  individual,  and  the  skin  should  be 
inspected  frequently.  The  plaster  may  be  applied  every  day  or  several 
times  a  day  according  to  the  effect  upon  the  skin  and  the  requirements  of 
the  case.     Mustard  mixed  with  white  of  egg  and  glycerine  instead  of 


TREATMENT  OTHER  THAN  BY  DRUGS  BY  THE  MOUTH        239 

with  water  is  less  likely  to  irritate.  The  application  of  mustard  in  the 
form  of  baths  or  packs  is  considered  later  (p.  242). 

Pepper  plasters  and  nutmeg  plasters  were  formerly  favorites  and  are 
sometimes  useful.  Lard  or  mutton-suet  is  spread  upon  a  piece  of  muslin 
and  liberally  dusted  with  black  pepper  or  powdered  nutmeg.  The  plaster 
should  be  worn  continuously,  until  sufficient  irritation  is  produced. 

Friction  with  turpentine  and  oil,  oil  of  amber,  soap  liniment,  camphor- 
ated oil  and  the  like  is  often  of  much  value  in  bronchitis,  adenitis,  and 
other  inflammations.  The  substance  should  be  rubbed  on  with  the  hand 
or  with  a  small  piece  of  flannel  until  the  skin  is  slightly  reddened.  In 
the  case  of  many  infants  it  seems  impossible  to  produce  satisfactory 
counter^irritation  in  this  way,  and  the  mustard  plaster  is  then  to  be 
preferred. 

The  spice  bag  is  an  old-fashioned  but  verj^  excellent  application  for 
colic  in  early  infancy.  Equal  parts  of  ground  ginger,  cloves,  cinnamon, 
and  allspice  are  mixed  and  put  into  a  small  square  flannel  bag  and  spread 
evenly.  The  bag  is  then  quilted  to  keep  the  powder  in  place.  Before 
applying  it  should  be  wet  with  hot  alcohol-and-water  or  with  bathing 
whiskey.  The  same  bag  may  be  used  repeatedly  until  it  begins  to  lose 
strength  too  greatly. 

Turpentine  stupes  are  serviceable  in  abdominal  pain  or  tympanities. 
A  piece  of  flannel  is  wrung  out  in  very  hot  water  and  sprinkled  evenly  with 
turpentine,  about  half  a  teaspoonful  being  used  for  each  square  foot  of 
flannel.  It  is  then  applied  and  covered  with  oiled  silk  and  a  dry  cloth. 
Its  action  must  be  watched  lest  too  much  irritation  result. 

Dry  cups  are  occasionally  useful  in  cases  of  severe  bronchitis,  broncho- 
pneumonia, nephritis  or  passive  congestion  of  the  lungs  from  cardiac 
disease.  Their  action  is  more  powerful  than  that  of  friction  or  mustard 
plasters. 

11.  Hydrotherapy.- — The  employment  of  water  as  a  remedial 
measure,  applied  to  the  surface  of  the  body  in  general  or  to  portions  of  it, 
is  one  of  the  most  important  of  therapeutic  agents  in  infancy  and  child- 
hood. Yet  one  of  the  greatest  principles  attaching  to  it  is  that  hydro- 
therapy is  not  intended  solely  or  eA''en  chiefly  for  the  reduction  of  tem- 
perature. It  serves  many  useful  purposes  in  afebrile  states;  while  when 
employed  for  patients  with  fever  its  favorable  action  is  to  be  measured 
not  so  much  by  the  degree  of  the  reduction  of  temperature  as  by  the 
other  good  effects  produced.  Hydrotherapy  is  often  a  harmful  measure 
when  used,  as  it  too  frequently  is,  with  the  apparent  determination  on  the 
part  of  the  physician  to  reduce  the  temperature  of  the  body  at  any  cost. 
Fever  is  only  a  symptom,  and  unless  unduly  high  or  prolonged,  not 
one  which  docs  harm. 

General  baths  may  be  divided  into  (a)  sponge  baths,  (b)  tub  baths, 
(c)  shower  baths,  ((/)  sheet  baths,  (e)  vapor  baths,  (/)  medicated  baths. 
Of  the  local  baths  may  be  mentioned  ((j)  foot-baths,  {h)  compresses  and 
fomentations.  Baths  may  also  be  classified  according  to  the  temperature 
of  the  water.  A  convenient  approximate  classification  is  into:  (1) 
Cold  bath  (40°  to  70°F.)  (4.4°  to  2I.1°C.);  (2)  Cool  bath  (70°  to  80°F.) 
(21.1°  to  2G.7°C);  (3)  Tepid  Imth  (80°  to  90°F.)  (2G.7°  to  32.2°C.) ;  (4) 
Graduated  bath  (85°  to  90°F.)  (29.4°  to  32.2°C.)  reduced;  (r>)  Warm 
bath  (90°  to  10()°F.)  (32.3  to37.8°C.);  (0)  Hot  bath  (100°  to  105°F.)  (37.8° 
to  40.6°C.). 

(a)  The  sponge  bath  with  warm  water  should  be  employed  daily  in 
nearly  every  case  of  illness.     The  child  should  be  undressed  completely 


240  THE  DISEASES  OF  CHILDREN 

and  laid  between  blankets.  The  sponging  should  be  done  with  care 
and  without  exposure,  one  part  of  the  body  being  thus  washed  and  dried 
before  another  is  approached.  Cool  or  tepid  sponging  is  of  great  value 
for  the  reduction  of  temperature,  and  is  often  in  early  life  as  serviceable 
as  is  the  whole  bath  in  the  case  of  adults.  There  is  not  the  same  need 
of  the  precaution  alluded  to  against  exposure  of  the  body,  since  reduction 
of  temperature  is  the  object  in  view.  The  sponging  should  be  continued 
for  from  5  to  15  minutes,  avoiding  the  production  of  decided  cyanosis  or 
long-continued  depression  of  the  pulse-strength.  Some  degree  of  pallor 
and  of  lessening  of  the  force  of  the  pulse  is  a  frequent  result,  and  con- 
siderable judgment  is  required  to  determine  whether  or  not  the  bath  is 
doing  harm.  Some  children  with  fever  do  not  bear  cool  sponging  or  even 
tepid  sponging  at  all  well. 

(b)  The  warm  tub  bath  is  an  excellent  measure  in  depressed  conditions 
in  the  eruptive  fevers  marked  by  a  retrocession  of  the  eruption.  Through 
its  action  the  cardiac  strength  improves  and  the  rash  consequently 
reappears.  It  is  also  a  useful  antipyretic  measure  at  the  beginning  of 
nearly  any  acute  febrile  disease,  and  is  often  serviceable  in  reducing 
temperature  in  continued  fevers  when  a  cooler  bath  is  not  well  borne. 
It  is  a  diaphoretic  in  cases  of  nephritis;  is  an  excellent  sedative  in  great 
nervous  excitement,  insomnia  or  convulsions;  relaxes  the  spasm  of  false 
croup,  and  reduces  the  temperature  and  relieves  the  dyspnea  of  broncho- 
pneumonia. Care  must  be  taken  to  avoid  exposure.  The  room  should 
be  warm,  the  child  kept  in  the  bath  from  5  to  20  minutes,  according  to  the 
effect,  and  wrapped  in  blankets  with  little  drying  as  soon  as  removed 
from  the  water.  In  most  cases  of  fever  in  infancy  and  early  childhood 
it  is  much  to  be  preferred  to  sponging. 

The  hot  tub  bath  is  a  powerful  stimulant,  serviceable  in  cases  of  severe 
exhaustion  or  collapse,  or  when  the  vital  powers  are  failing  and  atalectasis 
developing,  as  in  cases  of  premature  birth  or  of  bronchopneumonia 
in  weakly  infants.  The  temperature  of  the  water  should  be  100°F. 
37.8°C.)  to  not  over  105°F.,  (40.6°C.)  determined  by  the  thermometer,  and 
the  infant  should  be  immersed  for  not  more  than  3  minutes.  Occasionally 
the  procedure  seems  to  do  more  harm  than  good,  and  to  hasten  the 
fatal  ending  which  was  inevitable.  In  other  cases,  however,  the  good 
results  are  surprising  and  justify  any  risk  which  may  attend  the 
measure. 

The  tepid  tub  bath  and  the  graduated  tub  bath  are  useful  antip.yretic 
measures  where  sponging  or  the  warm  bath  fails.  In  the  graduated  bath 
the  water  is  90°F.  (32.2°C.)  at  the  start  and  is  gradually  cooled  down 
to  80°  (26.7°C.)  or  sometimes  less.  Most  older  children  bear  bathing 
of  this  sort  well  and  the  measure  is  very  serviceable  in  continued  fevers, 
and  often  fatigues  the  patient  less  than  sponging.  Many  children, 
however,  are  not  benefited,  and  some  do  not  tolerate  baths  of  this 
temperature.  It  is  well  to  bear  this  in  mind  and  not  to  persist  with 
bathing  merely  because  fever  continues.  The  child  should  be  in  the 
water  from  5  to  10  minutes,  being  vigorously  rubbed  meanwhile,  and 
carefully  watched  against  too  great  depression.  In  very  hot  weather, 
when  an  infant  appears  to  be  exhausted  by  the  continued  heat,  it  is 
sometimes  of  advantage  to  give  several  tepid  tub-baths  daily  for  their 
bracing  and  cooling  effect. 

The  cool  and  cold  tub  baths  are  not  often  needed  in  childhood  except 
in  cases  of  very  great  hyperpyrexia,  such  as  develops  in  sunstroke  and 
sometimes  in  pneumonia  and  the  eruptive  fevers.     In  giving  cold  baths 


TREATMENT  OTHER  THAN  BY  DRUGS  BY  THE  MOUTH       241 

under  these  conditions  the  temperature  of  the  child  must  be  constantly 
watched  and  the  bath  stopped  before  apyrexia  is  reached. 

(c)  The  shower  bath  or  afifusion,  is  an  excellent  tonic  and  stimulant 
for  delicate  children.  The  child  should  stand  in  a  tub  of  warm  water  in  a 
warm  room.  The  cooler  water  may  then  be  applied  from  an  ordinary 
shower  apparatus,  or  may  be  poured  over  the  head  and  trunk  from  a 
pitcher  or  squeezed  from  a  large  sponge.  The  duration  of  the  affusion 
should  be  brief,  a  minute  or  less  being  sufficient,  followed  by  brisk  rub- 
bing with  a  Turkish  towel.  The  water  lasiy  be  tepid,  cool,  or  cold, 
according  to  the  strength  of  the  child  and  the  degree  or  reaction  which 
follows.  If  this  latter  is  not  satisfactory,  warmer  water  should  be  used 
or  the  shower  bath  not  employed  at  all. 


Fig.  39. — Apparatus  for  Giving  a  Hot-air  Bath. 

Rul)ber  sheet  and  outer  blanket  turned  back  to  show  the  supporting  hoops  above  the 
child.  Covered  metal  pipe  conducts  the  hot  air  beneath  the  coveriuKs  at  the  foot  of 
the  bed. 

{d)  The  sheet  bath,  or  wet  pack,  may  be  either  hot  or  cold.  To  apply 
a  cold  pack  a  rubber  cloth  is  put  over  the  bed  and  a  sheet,  previously 
wrung  out  in  cold  water,  laid  upon  it.  The  child  is  now  stripped,  placed 
upon  and  envcl()i)ed,  except  the  head,  in  the  sheet,  and,  outside  of  this, 
in  a  l)lanket.  It  is  often  advisable  to  leave  the  feet  out  and  to  put  a  hot 
water  bag  to  them.  The  child  may  receive  a  second  pack  in  15  or  21) 
minutes,  or  may  be  left  in  the  first  for  an  hour  or  more  if  it  has  fallen 
asleep.  When  removed  from  the  pack  it  should  be  wrapped  in  a  warm 
(liy  blanket. 

The  cold  pack  applied  in  this  way  is  useful  for  quieting  neivousness 
and  often  for  reducing  moderate  fever.  When  a  more  decided  antipy- 
retic action  is  desiied  it  is  necessary  to  renew  the  pack  every  5  minut(>s 

16 


242  THE  DISEASES  OF  CHILDREN 

several  times  in  succession,  sometimes  using  ice  water,  but  only  if  the 
temperature  of  the  body  is  excessively  high.  It  is  often  more  convenient 
to  substitute  cloths  dipped  in  ice  water  for  the  sheet,  since  these  may  more 
easily  be  removed,  remoistened  and  replaced.  The  wrapping  in  the  blan- 
ket may  be  omitted  in  these  cases.  A  cold  cloth  must  always  be  kept  to 
the  head. 

The  hot  pack,  or  blanket  bath,  is  given  by  covering  the  child  with  towels' 
wrung  out  in  hot  water,  or  wrapping  it  in  a  blanket,  similarly  treated; 
and  then  enveloping  in  several  dry  blankets.  The  pack  may  be  renewed 
in  half  an  hour.  The  hot  pack  is  often  serviceable  for  producing  free 
perspiration  in  cases  of  nephritis. 

(e)  The  vapor  bath  is  employed  to  cause  profuse  perspiration  in 
nephritis.  The  bed  is  well  covered  by  a  blanket  and  the  child  is  stripped 
and  laid  upon  this.  Other  blankets  are  then  thrown  over  the  child, 
reaching  nearly  or  quite  to  the  floor,  but  kept  away  from  the  body  by 
half  barrel-hoops,  a  chair  in  the  bed,  or  some  other  support  (Fig.  39) 
except  where  they  are  tucked  in  closely  about  the  neck.  Into  the  air- 
space thus  formed  about  the  child  vapor  is  now  conducted  from  a  croup- 
kettle.  The  process  is  continued  from  15  to  30  minutes  if  the  child 
tolerates  it  well.  Care  must  be  taken  that  the  vapor  does  not  play  di- 
rectly against  the  body,  since  unconscious  children  have  repeatedly  been 
severely  burned  in  this  way.  In  the  absence  of  a  croup-kettle,  vapor  may 
be  produced  beneath  the  bed  by  slaking  lime,  or  by  hot  iron  dropped  into 
water,  the  vapor  being  given  an  opening  through  which  it  can  rise  and 
surround  the  child. 

The  hot  air  bath  is  applied  in  a  similar  manner  and  for  the  same  pur- 
pose, dry  hot  air  from  an  alcohol  lamp  or  small  gas-stove  being  conducted 
under  the  covers  by  a  tin  pipe  (Fig.  39).  With  either  procedure  every 
precaution  must  be  taken  against  the  igniting  of  the  bed  clothing. 

(/)  Medicated  baths  are  of  much  service  in  childhood.  The  warm 
or  hot  mustard  tub-bath  is  a  powerful  stimulant  in  cases  of  cardiac  failure 
or  where  for  any  reason  it  is  desired  to  bring  the  blood  to  the  sur- 
face of  the  body.  Often  the  good  results  obtained  are  surprising.  Mus- 
tard is  added  to  the  water  in  the  proportion  of  1  oz.  (28)  (6  level 
tablespoonfuls)  to  1  gallon  (3785)  of  water.  The  duration  of  immersion 
should  be  10  minutes,  or  less  if  the  skin  has  become  well  reddened  or  if 
the  bath  is  not  well  borne.  The  development  of  a  sensation  of  tingling 
produced  by  the  mustard  water  on  the  nurse's  arms  is  also  an  indication 
to  remove  the  child.  The  mustard-pack  is  a  convenient  and  useful 
application  in  cases  of  prostration  or  collapse  where  the  physician  fears 
the  greater  disturbance  of  the  tub  bath.  The  child  is  stripped  as  for  the 
ordinary  pack,  laid  upon  a  blanket,  and  covered,  except  the  head,  with  a 
cloth  dipped  in  hot  mustard  water,  slightly  stronger  than  that  used  for 
the  tub  bath.  The  blanket  is  then  wrapped  around  the  body.  The 
pack  may  continue  for  10  minutes  or  more  according  to  the  degree  of 
redness  of  the  skin  which  it  produces.  A  very  efficient  method  of  apply- 
ing a  powerful  mustard-pack  is  recommended  by  Heubner.^  I  have 
seen  it  occasionally  produce  surprising  results  in  patients  apparently 
almost  moribund.  Heubner  advises  the  mixing  of  "2  handfuls  of 
mustard-flour  to  a  liter  of  warm  water,  and  stirring  thoroughly  until  the 
odor  of  the  mustard  has  become  distinctly  irritating  to  the  nose  and  eyes. 
A  cloth  is  now  dipped  in  the  mustard  water,  wrung  out  slightly,  and 

iLehrb.  d.  Kinderh.,  1911,  II,  269. 


TREATMENT  OTHER  THAN  BY  DRUGS  BY  THE  MOUTH       243 

wrapped  completely  about  the  patient  up  to  the  neck,  and  a  blanket 
wrapped  outside  of  this.  The  child  remains  in  the  pack  10  minutes, 
and  is  then  washed  quickly  and  thoroughly  with  warm  water,  and  re- 
enveloped  in  a  fresh  pack  of  simple  warm  water,  where  it  remains  2  to 
3  hours." 

The  starch  hath  may  be  made  of  the  strength  of  3^^  cupful  of  boiled 
starch  to  every  4  gallons  (15,142)  of  water.  If  the  starch  has  already  jellied 
it  may  be  reheated,  or  pressed  through  moistened  cheese-cloth.  This 
bath  is  useful  in  some  affections  of  the  skin.  Starch  water  for  washing 
the  skin  may  be  made  in  the  same  way. 

The  soda  hath  consists  of  a  solution  of  1  tablespoonful  of  carbonate  of 
soda  (washing  soda)  to  every  4  gallons  (15,142)  of  water.  It  is  used  for 
the  same  purposes  as  the  starch  bath,  and  is  often  combined  with  it  by 
dissolving  the  soda  in  the  starch  water. 

Salt  baths  have  been  much  used  as  a  tonic  treatment  for  debilitated 
children,  particularly  those  with  rickets.  Rock  salt,  coarse  table  salt, 
or  preferably  dried  sea-salt  may  be  dissolved  in  water  in  the  propor- 
tion of  4  oz,  (113)  (10  level  tablespoonfuls)  to  1  gallon  (3785)  of  water. 
The  child  may  be  washed  with  or  immersed  in  this  after  having  had  the 
soap  suds  of  the  ordinary  washing  removed  with  plain  water.  The  dura- 
tion of  immersion  depends  on  the  temperature  of  the  water  and  the  condi- 
tion of  the  case  in  general.  Doubtless  salt  baths,  if  sufficiently  cool, 
do  good,  but  whether  this  is  in  any  way  due  to  the  presence  of  the  salt 
is  questionable. 

The  hran  hath  is  made  by  putting  1  lb.  (454)  (about  3  pints)  or 
more  of  bran  into  a  thin  muslin  bag  and  boiling  this  in  water  for  a  quarter 
of  an  hour.  This  water  is  then  added  to  that  of  the  bath  until  the  whole 
is  slightly  milky  in  appearance.  Bran  baths  have  been  employed  in  many 
irritated  conditions  of  the  skin  in  infants  and  children. 

The  sulphur  hath,  used  sometimes  in  chronic  rheumatic  disorders 
and  in  some  affections  of  the  skin,  is  made  by  dissolving  20  grains  (1.3) 
of  potassium  sulphide  in  each  gallon  (3785)  of  water  employed.  It  can- 
not be  given  in  a  metal  tub. 

Disinfecting  baths  are  employed  after  recovery  from  infectious  diseases. 
They  may  consist  of  a  2  per  cent,  solution  of  carbolic  acid,  for  older  chil- 
dren or  of  liquor  sodaechlorinatae,  diluted  to  the  strength  of  (ifl.  oz.  (177)  to  1 
gallon  (3785)  of  water.  A  solution  of  corrosive  sublimate  of  the  strength 
of  1  :  10,000  may  be  used  instead. 

Various  mineral  springs  furnish  whole  medicated  baths  useful  in 
many  affections,  notably  those  of  Nauheim  for  the  treatment  of  cardiac 
diseases,  and  various  hot  sulphur  springs  for  rheumatic  conditions. 
Modifications  of  the  Nauheim  baths  may  be  given  at  home. 

(</)  Of  the  local  baths  the  foot-bath  is  one  of  the  most  serviceable  for 
older  children.  It  is  generally  given  in  the  form  of  the  hot  nmstard  foot- 
l)ath,  of  the  strength  of  1  oz.  (28)  (2  moderately  heaping  tablespoonfuls) 
of  nmstard  to  1  gallon  (3785)  of  water.  Care  must  be  observed  that  the 
room  is  warm  and  the  bed-clothes  also.  The  child,  dressed  in  its  night- 
clothes,  sits  on  the  edge  of  the  bed,  well  wrapped  with  blankets,  including 
the  thighs,  while  the  feet  and  legs  are  in  the  tub  of  nuistard  water.  After 
5  or  1()  minutes  the  feet  arc  rapidly  dried  and  wrapped  in  a  warmed 
blanket,  and  the  child  put  to  bed.  l*]xposure  is  avoided  even  more 
completely  if  the  tub  is  in  the  bod  under  the  covers,  while  the  child  lies 
with  the  knees  drawn  up  and  the  feet  in  the  mustard  water. 


244  THE  DISEASES  OF  CHILDREN 

(h)  Compresses  and  fomentations  constitute  what  may  be  called 
local  forms  of  baths.  Cold  compresses  consist  of  thin  cloth,  folded  into 
several  layers,  dipped  in  ice  water,  wrung  out  and  laid  on  the  affected 
part.  They  must  be  light,  not  wet  enough  to  drip,  and  changed  every 
few  minutes.  They  are  serviceable  in  inflammation  of  the  eyes,  sprains, 
etc.  Hot  compresses,  or  fomentations,  are  made  of  flannel  in  several 
layers,  which  has  been  wrung  out  in  water  as  hot  as  can  be  borne.  This 
wringing  is  conveniently  done  by  dropping  the  wet  flannel  into  a  dry 
towel  and  then  thoi^oughly  twisting  this.  The  nurse  then  tests  the  flannel 
against  her  cheek,  applies  it  quickly  to  the  part,  and  covers  it  with  oil- 
silk  and  then  with  dry  flannel  or  a  dry  towel.  It  should  be  renewed  in 
an  hour,  or  less  if  it  is  desired  to  maintain  decided  heat. 

(i)  Poultices. — The  poultice  is  intended  to  furnish  a  wet  dressing 
which  will  retain  heat  longer  than  a  fomentation.  It  is  commonly 
composed  of  flaxseed  meal,  but  other  substances  may  be  used  instead, 
such  as  cornmeal,  bread,  starch,  slippery-elm,  etc.,  according  to  circum- 
stances. The  flaxseed  poultice  is  made  by  stirring  ground  flaxseed  into  a 
small  quantity  of  water  nearly  or  quite  boiling,  until  it  is  of  the  consis- 
tency of  hot  mush,  too  thick  to  flow.  This  is  spread  with  a  case-knife 
upon  a  thick  piece  of  cotton  or  linen  cloth,  the  edges  folded  over  slightly, 
and  the  whole  covered  with  cheese-cloth,  gauze  or  a  thin  old  pocket  hand- 
kerchief. The  nurse  should  test  it  against  her  cheek  to  see  that  it  is  not 
too  hot,  apply  it,  cover  it  with  oil-silk  or  paraffin  paper,  and  enclose  with 
a  bandage.  It  should  be  renewed  every  few  hours  if  the  heat  is  to  be- 
maintained.  The  slippery-elm  poultice  and  the  cornmeal  poultice  are 
prepared  in  the  same  way,  from  ground  elm  bark  or  from  cornmeal. 
They  have  no  special  advantages  over  the  flaxseed  poultice.  The  hread- 
and-milk  poultice  is  popular  and  easily  prepared.  Stale  bread  crumb  is 
stirred  into  hot  milk  until  the  proper  consistency  is  attained.  It  is  then 
spread  as  described.  Any  of  these  poultices  are  applicable  to  many  cases 
of  local  inflammation  when  there  is  no  open  wound.  In  the  latter  case 
an  antiseptic  fomentation  is  generally  preferred. 

In  many  cases  of  pain  and  tenderness,  as  in  some  abdominal  affec- 
tions, where  a  flaxseed  poultice  would  be  too  heavy,  a  hraii  poultice  may 
be  substituted.  A  flannel  bag  is  partly  filled  with  bran,  thoroughly  wet 
with  boiling  water,  wrung  out  in  a  towel,  and  applied.  In  place  of  this 
a  hop  poultice  may  be  prepared  in  the  same  way.  Neither  of  these  are 
as  popular  as  formerly.  The  mustard  poultice  has  been  described  in 
considering  counter-irritants.  The  jacket  poultice  and  the  cotton  jacket, 
the  latter  if  properly  made  acting  somewhat  like  a  poultice,  are  ap- 
parently going  more  and  more  out  of  vogue;  it  seems  to  me  with  good 
reason. 

12.  Dry  Cold.^ — ^This  may  be  applied  by  coils  of  small  lead  or  rubber 
tubing,  fitted  to  the  affected  part,  and  through  which  cold  water  is  con- 
ducted (Leiter's  coils).  A  more  convenient  method,  however,  is  the 
employment  of  ice-bags.  Applied  to  the  head  an  ice-bag  is  often  of 
benefit  for  reducing  temperature  in  febrile  diseases;  applied  over  the  abdo- 
men it  is  even  more  effective  for  this- purpose.  It  often  jiives  relief  from 
the  pain  of  pleurisy  or  cardiac  disease.  Ice  is  also  useful  applied  below 
the  ears  in  cases  of  tonsilitis.  The  bags  employed  should,  however, 
be  of  thin  rubber.  The  long  sausage-shaped  bag  of  thick  rubber  generally 
sold  for  application  to  the  neck  is  not  serviceable.  The  ice-bag  used  in 
any  region  of  the  body  should  never  be  quite  filled  or  it  cannot  adapt 
itself  well.     The  local  employment  of  ice  must  be  watched  very  care- 


TREATMENT  OTHER  THAN  BY  DRUGS  BY  THE  MOUTH       245 

fully,  and  is  more  suitable  for  older  children  than  for  young  infants.  In 
the  latter  it  may  cause  dangerous  depression.  It  is  often  best  to  insert 
one  or  more  layers  of  thin  cloth  between  the  bag  and  the  skin  to  prevent 
harmful  action  upon  the  latter. 

13.  Dry  Heat.- — This  is  useful  particularly  for  the  rehef  of  pain 
and  for  the  treatment  of  chronic  articular  affections.  In  acute  painful 
conditions,  such  as  otitis;  for  the  relief  of  shock  or  collapse;  and  for  low 
temperature  in  marantic  or  premature  infants  the  employment  of  hot 
water  bags  or  bottles  constitutes  an  excellent  therapeutic  procedure. 
For  chronic  articular  inflammation  dry  heat  may  be  applied  by  baking 
in  a  special  apparatus  made  for  the  purpose,  or  by  the  use  of  radiant 
heat  from  a  group  of  electric  lamps.  With  all  infants  and  in  unconscious 
states  at  any  age  precautions  must  be  carefully  taken  against  burning 
the  patient. 

14.  Blood=letting. — Venesection  is  not  suitable  for  infancy  and 
early  childhood  and  only  rarely  indicated  in  older  children.  There  are 
exceptional  cases  of  uremia  or  of  acute  distention  of  the  right  side  of  the 
heart  where  it  does  good.  Local  blood-letting  by  wet  cups  should  rarely 
be  employed  except  in  strong  subjects  in  later  childhood.  Leeching 
may  occasionally  be  serviceable  in  dilatation  of  the  right  side  of  the  heart, 
uremia,  otitis,  meningitis,  and  pneumonia  in  strong  children. 

15.  Vaccine  and  Serum  Therapy.- — This  method  of  treatment 
has  come  of  recent  years  into  great  prominence,  but,  like  all  new  methods, 
has  been  overrated,  while  possessing  undoubted  value  in  some  conditions. 
Vaccine  treatment  consists  in  the  hypodermic  administration  of  a  sus- 
pension of  dead  bacteria.  As  a  prophylactic  measure  for  typhoid  fever 
it  appears  certainly  to  have  established  its  position,  and  for  the  treat- 
ment of  the  attack  it  seems  to  be  of  value.  In  most  of  the  streptococcic 
infections  the  usefulness  of  vaccines  is  doubtful.  Sometimes  they  seem 
to  do  good  in  erysipelas,  and  the  treatment  is  well  worth  trying.  Staphy- 
lococcic infections  offer  a  better  field,  especially  in  suppurative  processes 
in  the  skin.  The  value  of  vaccine  in  pertussis  is  still  under  discussion,  and 
it  must  be  stated  that  the  efficacy  of  the  treatment  has  at  least  not  been 
proven.  The  same  may  be  said  regarding  the  employment  of  gonococcus 
vaccine  in  vulvo-vaginitis,  and  of  that  of  the  colon  bacillus  in  pyelitis. 
Instances  are  on  record  of  decided  apparent  benefit;  while  other  investi- 
gators have  failed  to  accomplish  any  good  whatever. 

The  employment  of  sera,  or  of  the  extractive  matter  from  bacteria, 
is  of  somewhat  older  date,  but  occupies  a  very  limited  field  of  usefulness. 
The  serviceableness  of  the  diphtheria  antitoxin  is  beyond  question,  as 
also  seems  to  be  that  of  the  serum-treatment  for  cerebrospinal  fever; 
and  that  for  pneumonia  is  encouraging.  Tuberculin  has  not  maintained 
the  position  once  hoped  for  it,  and  is  a  remedy  by  no  means  without 
danger.  The  serum-treatment  of  scarlet  fever  has  not  established  itself 
in  the  opinion  of  most  physicians,  although  it  may  be  perhaps  of  value 
in  the  management  of  the  complications.  In  certain  hv^morrhagic  con- 
(Utions  the  injection  of  a  foreign  serum,  or  even  of  human  serum  or  of 
l)lood  itself,  a{)pears  to  be  distinctly  beneficial  in  controlling  the  lileoding. 

16.  Intra=venoiis  Injections. — The  employment  of  this  procethire 
is  considerably  interfered  with  in  infancy  owing  to  the  difticulty  in  find- 
ing a  vein.  The  longitudinal  sinus  at  the  position  of  the  fontanelle 
may  be  used  instead.  In  older  children  the  procedure  is  occasionally 
useful  in  cases  of  collapse,  as  after  profuse  hemorrhage,  using  a  sterilized 
warm  normal  salt-solution  (0.9  per  cent.).     The  treatment   of  syphilis 


246 


THE  DISEASES  OF  CHILDREN 


by  arsphenamine  is  preferably  given  intravenously.  Sodium  bicarbonate 
may  be,  given  intravenously  m  cases  of  acidosis  (see  p.  232),  or  a  5 
per  cent,  solution  of  dextrose  in  severe  malnutrition  in  gastrointestinal 
disorders. 

17.  Transfusion  of  Blood. — The  introduction  of  blood  from  a 
human  subject  into  the  veins  of  a  patient  has  been  found  useful  in  cases 
of  hemorrhage  or  of  severe  anemia  from  other  causes.  It  has  also  been 
employed  successfully  in  hemorrhagic  diseases  in  the  new-born.  The 
transfusion  may  be  accomplished  directly  into  the  vein  from*the  circu- 
lation of  the  individual  furnishing  the  blood,  or  the  blood  may  be  aspi- 
rated into  a  glass  syringe  and  then  promptly  injected  into  one  of  the  large 
veins  of  the  child,  preferably  the  median  cephalic  or  the  external  jugular. 


Fig.  40. — The  Performance  of  Lavage  of  the  Stomach. 

Either  procedure  requires  technical  skill,  the  first  especially  so.  The 
simplest  method  is  the  employment  of  a  citrated  blood,  using  1  part  of 
a  sterilized  2.5  per  cent,  solution  of  sodium  citrate  and  4  parts  of  blood. 
This  prevents  coagulation.  With  any  method  it  is  essential  first  to  test 
the  agglutinative  action  of  the  blood  of  the  recipient  and  of  the  donor  upon 
each  other,  or  dangerous  hemolysis  may  take  place  (Minot).^  From  1 
to  2V^  fl.oz.  (30  to  75)  of  blood  may  be  injected  at  the  age  of  6  months  or 
less;  3  to  4  fl.oz.  (89  to  118)  at  1  year,  and  4  to  6  fl.oz.  (118  to  177)  at 
2  or  3  years  (Zingher).^ 

18.  Lavage. — Very  frequently  obstinate  acute  or  chronic  vomiting 
will  be  made  to  cease  by  lavage  after  the  administration  of  drugs  has 
failed  entirely.  A  stomach-tube  is  employed,  composed  of  a  soft  rubber 
catheter,  No.  13  or  14  American  scale,  connected  by  a  piece  of  thin  glass- 

1  Boston  Med.  and  Surg.  Jour.,  1916,  CLXXIV,  667. 

2  Med.  Rec,  1915,  LXXXVII,  440. 


TREATMENT  OTHER  THAN  BY  DRUGS  BY  THE  MOUTH       247 

tube  to  a  section  of  soft  rubber  tubing,  the  other  end  of  which  is  attached 
to  a  funnel  of  hard  rubber  or  glass.  The  infant  sits  in  the  lap  of  the 
mother  while  the  nurse  introduces  the  end  of  the  catheter  moistened  with 
water  or  glycerin  (Fig.  40)  into  the  mouth  and  gently  but  quickly  passes 
it  backward  into  the  pharynx  and  downward  into  the  stomach.  A 
slight  resistance  is  felt  as  the  tube  reaches  the  beginning  of  the  esophagus. 
The  finger  of  the  left  hand,  placed  upon  the  tongue,  may  be  used  as  a 
depressor  and  a  guide.  There  is  very  little  danger  of  the  tube  entering 
the  larynx,  but  should  it  do  so  violent  coughing  and  cessation  of  breath- 
ing will  inform  us  of  the  fact.  About  10  inches  (25  cm.)  of  the  catheter 
should  be  inserted,  measuring  from  the  gums.  The  funnel  is  then  raised 
slightly  to  permit  gas  to  escape  and  the  solution  is  then  poured  into  it 
and  allowed  to  find  its  way  into  the  stomach.  Pinching  the  tube  between 
the  finger  and  thumb  and  sliding  these  along  it  toward  the  mouth  is  some- 
times needed  to  start  the  flow. 

After  from  4  to  8  fl.oz.  (118  to  237)  have  been  given  the  funnel 
is  lowered  as  far  as  possible,  in  order  to  syphon  out  the  gastric  con- 
tents into  a  basin.  The  tube  is  then  pinched  to  prevent  air  from 
entering,  the  funnel  raised  and  more  fluid  poured  in.  This  process  is 
repeated  several  times  until  from  a  pint  to  a  quart  (473  to  946)  of  fluid 
has  been  employed  and  the  washings  come  away  clear  of  curds  or  mucus. 

The  solution  ordinarily  used  is  a  warm  (100°  to  1 10°F.)  (37.8°  to  43.3°C.) 
normal  saline  solution  (0.9  per  cent.),  simple  boiled  water,  or,  where  there 
is  much  mucus,  an  alkaline  solution  containing  1  per  cent,  of  bicarbonate 
of  soda.  The  procedure  is  entirely  without  danger,  very  easy  to  carrj^  out 
during  infancy,  and  causes,  as  a  rule,  little  or  no  exhaustion.  It  maybe 
performed  daily  until  no  longer  needed. 

19.  Qavage.- — ^The  forced  feeding  of  infants  is  so  closely  connected 
with  lavage  that  it  may  well  be  described  in  this  connection.  After  the 
stomach  has  been  washed,  the  tube  may  be  left  in  position  and  the  child 
fed  through  it.  The  funnel  should  be  held  elevated  for  a  moment  before 
the  food  is  poured  into  it,  in  order  to  permit  gases  to  escape  from  the 
stomach.  Instead  of  sitting  the  child  should  be  flat  upon  its  back,  as 
it  is  less  likely  to  regurgitate  the  food  when  in  this  position.  For  the 
same  reason  the  ch'ld  must  be  kept  entirely  quiet  after  the  gavage 
is  over.  In  older  subjects  it  may  be  necessary  to  use  a  mouth-gag 
to  prevent  the  tube  from  being  bitten,  or  to  protect  the  finger  from 
the  child's  teeth.  When  the  tube  is  about  to  be  withdrawn  it  slrould  be 
pinched  tightly  to  prevent  food  from  dropping  from  it  into  the  pharynx, 
as  this  is  liable  to  induce  vomiting.  The  last  part  of  the  withdrawal 
should  also  be  done  very  quickly.  Should  vomiting  occur  immediately, 
a  second  gavage  may  sometimes  be  given  at  once  with  advantage. 

Gavage  is  very  easy  to  perform  and  is  extremely  useful  in  the  case  of 
infants  who  for  any  reason  are  unwilling  or  unable  to  take  sufficient 
nourishment,  or  in  those  where  vomiting  is  troublesome.  In  the  latter 
case  lavage  should  precede  each  gavage;  in  the  former  lavage  is  not  neces- 
sary. It  is  constantly  observed  that  food  given  by  gavage  will  often  be 
retained  much  better  than  when  swallowecl.  Cases  where  extreme  ano- 
rexia threatens  life  may  often  be  fed  with  success  by  gavage.  The  food 
may  sometimes  be  thoroughly  peptonized  with  advantage.  Sometimes 
it  must  be  weak  on  account  of  an  impaired  digestive  power;  in.othcr  cases, 
where  the  trouble  is  the  refusal  to  take  nourishment  in  the  ordinary  way, 
it  may  often  be  given  rather  stronger  and  in  larger  amount  than  usual, 
since  the  intervals  of  feeding  are  longer.     Children  may  be  fed  in  this 


248 


THE  DISEASES  OF  CHILDREN 


waj'  3  or  4  times  a  day,  or  occasionally  more  frequently.  In  some  cases 
where  Vomiting  or  lack  of  power  to  swallow  is  not  a  factor,  but  where 
unwillingness  to  take  food  is  the  cause,  it  is  not  necessary  for  the  tube 
actually  to  enter  the  esophagus,  but  a  short  piece  of  tvibing  may  be  passed 
through  the  mouth  to  the  pharynx  and  the  liquid  introduced  from  a  funnel 
or  syringe  through  this. 

20.  Nasal  Feeding. — In  older  children  where  the  jaws  are  tightly 
shut  and  a  mouth-gag  would  be  required  to  permit  of  inserting  a  tube 
into  the  esophagus,  it  is  better  to  feed  through  the  nose.  It  is  also  a 
serviceable  method  of  feeding  after  intubation.  The  procedure  is  simi- 
lar to  that  described  for  gavage,  except  that  a  smaller  tube  is  required, 
No.  8  or  10  American  scale  (Fig.  41).  In  some  instances  it  is  better  to  use 
the  nasal  tube  for  the  performing  of  lavage. 


Fig.  41. — Funnel  and  Tube  for  Nasal  Feeding. 

21.  Anesthesia.^ — Little  can  be  said  in  this  connection  which 
does  not  apply  to  adults  as  well.  As  a  rule  anesthetics  are  well  borne 
in  early  life.  There  is  a  possible  danger  of  sudden  death  in  cases  of 
lymphatism,  but  this  may  occur  in  those  of  older  age  as  well.  Ether  is  bj^ 
all  odds  the  safest  anesthetic  and  the  one  usually  to  be  preferred.  The 
excitement  and  resistance  which  it  occasions  may  be  avoided  by  begin- 
ning the  anesthetization  with  ethyl  chloride,  which,  however,  is  a  more 
dangerous  anesthetic  if  depended  on  solely,  particularly  in  infancy. 
Nitrous  oxide  may  be  used  in  the  same  way,  or  alone  for  short  operations 
in  older  children,  but  is  not  as  safe  for  infants.  Ether  is  generally  to 
be  avoided  in  diseases  of  the  lungs  and  in  nephritis.  Whether  ether 
or  chloroform  is  selected,  the  vapor  should  be  administered  slowly  and 
with  the  admixture  of  plenty  of  air;  and  this  applies  with  especial  force 
to  chloroform. 

22.  Psychotherapy. — The  enormous  importance  of  this  form  of 
therapeutics  in  early  life  is  too  frequently  overlooked.     Even  in  early 


TREATMENT  OTHER  THAN  BY  DRUGS  BY   THE  MOUTH       249 

infancy  it  is  seen,  for  instance,  in  the  good  effect  of  mental  quietude  or 
the  influence  of  a  calm  and  somewhat  phlegmatic  nurse  in  the  controlling 
of  troublesome  vomiting;  as  also  in  the  relief  of  insomnia  by  such  meas- 
ures as  the  avoidance  of  excitement  before  the  hour  for  sleep,  the  removal 
of  noise  or  light  from  the  room,  and  the  like.  In  older  children  the  insist- 
ence by  the  physician  that  the  mother  shall  not  speak  of  nervous  symp- 
toms in  the  presence  of  the  patient,  and  that  these  shall  be  in  every  way 
ignored,  is  something  we  cannot  afford  to  forget  if  good  results  are  to  be 
obtained.  The  remarkable  influence  of  complete  change  of  surroundings 
and  of  removal  from  association  with  over-anxious  parents  is  shown  by 
the  frequent,  prompt  disappearance  of  spasmodic  symptoms,  nervous  ano- 
rexia or  dysphasia,  or  other  nervous  manifestations  when  a  child  is  placed 
under  hospital  influences  or  sent  from  home  in  the  care  of  a  properly 
selected  nurse.  The  control  of  the  exhibition  of  anxiety  by  the  parents 
and  of  the  bad  methods  of  training  shown  by  them  is  often  the  principal 
and  the  most  difficult  object  of  treatment.  The  subject  is  too  large  for 
further  discussion  in  this  connection.  It  is  referred  to  brieflj'  to  some 
extent  in  the  chapter  upon  Diseases  of  the  Nervous  System,  and  I  have 
discussed  it  also  elsewhere.  ^ 

23.  Mechanotherapy. — Massage,  even  when  carried  out  in  a  very 
simple  and  unscientific  manner,  and  in  a  way  which  any  mother  can  do, 
occupies  a  valuable  place  in  the  therapeutics  of  infancy.  The  rubbing 
of  the  body  with  the  flat  of  the  hand,  lubricated  with  sweet  oil  or  cocoa 
butter,  is  an  excellent  procedure  in  feeble  circulation,  malnutrition, 
anemia,  and  paralytic  conditions.  Still  better  is  it  to  encircle  the  arm 
or  leg  of  the  infant  with  the  well-greased  thumb  and  forefinger,  and  to 
push  up  and  down  the  limb  with  the  exercise  of  considerable  pressure. 
More  effective  is  a  gentle  kneading  of  the  muscles  done  by  a  trained  mas- 
seuse. The  procedure  usually  soon  becomes  very  soothing  and  agreeable 
to  the  patient.  Care  must  alwaj^s  be  taken  to  avoid  undue  exposure  of 
the  body  lest  chilling  result.  In  older  children  a  more  systematic  mas- 
sage, given  by  one  experienced  in  the  method,  is  often  useful,  especially 
so  in  paralytic  or  pseudo-paralytic  states,  faulty  habits  of  sitting  or 
walking,  lateral  curvature  of  the  spine,  and  the  like.  Abdominal  mas- 
sage is  frequently  one  of  the  best  remedies  for  obstinate  chronic  constipa- 
tion. In  the  case  of  active  children  massage  does  not  fill  the  place  which 
it  does  with  adults,  since  the  child  takes  relatively  far  more  exercise  than 
the  average  man  undergoes. 

Resisted  movements  may  be  used  either  alone  or  combined  with 
massage.  They  are  serviceable,  for  instance,  in  some  cases  of  paralysis 
and  of  diseases  of  the  heart  and  for  the  training  of  any  especially  weak 
muscles. 

For  children  sufliciently  old  gymnastic  exercises  are  of  great  value 
conducted  by  a  trained  observer  and  selected  to  meet  the  needs  of  the 
individual  case.  Even  without  such  an  advantage,  a  series  of  exercises 
can  be  chosen  by  the  physician  and  supervised  by  an  intelligent  mother 
or  nurse  in  the  patient's  home.  These  may  ])e  used  to  overcome  the 
results  of  faulty  habits  of  standing,  sitting  or  walking;  distortions  of  the 
chest  following  rachitis  or  plcuiisy,  or  defonnities  acquired  in  other  ways. 
It  is  necessary,  of  course,  to  know  the  action  of  the  difTorcnt  muscles  and 
to  outline  special  exercises  to  bring  these  into  play.  The  reader  may  be 
referred  to   treatises   upon  exercise  and  u|)on  orthopedic  surgery,  and 

'  New  York  Med.  Jour.,  I'Jl 4,  .Jiiiip  (i. 


250  THE  DISEASES  OF  CHILDREN 

especially  to  the  interesting  contribution  by  Keating  and  Young  upon 
Physical  Development.^ 

Rest,  with  or  without  isolation,  is  often  most  important.  Thus  in 
chorea,  many  cases  of  cardiac  disease,  epilepsy,  and  hysteria  it  is  by  far 
the  most  important  part  of  the  treatment.  The  fact  that  nervous,  active 
children  are  constantly  liable  to  take  by  far  too  much  exercise  is  always 
to  be  remembered.  In  such  cases  systematic  enforced  rest  during  a 
portion  of  the  day  is  to  be  enjoined.  Many  functional  nervous  disturb- 
ances may  be  aided  by  the  prescribing  of  recumbent  rest  for  an  hour  in 
the  middle  of  the  day.  That  the  child  sleep  at  this  time  is  an  advantage, 
but  need  not  be  insisted  upon.  If  he  is  wakeful  or  restless,  he  may  be 
allowed  to  look  at  a  picture-book  or  to  have  some  not  too  exciting  story 
read  to  him. 

Electricity  is  a  useful  form  of  mechanotherapy  in  paralytic  conditions 
and  in  some  other  affections.  The  fright  which  the  application  may 
cause  often  interferes  largely  with  the  benefit  which  might  be  expected. 
Only  the  weakest  current  should  be  employed  at  first,  and  never  one  of. 
sufficient  strength  to  cause  pain.  Indeed,  the  first  application  may  well 
be  that  of  the  wet  sponges  alone,  the  battery  being  in  action  but  uncon- 
nected. The  current  to  be  chosen  depends  upon  the  nature  of  the  disease. 
As  a  mere  matter  of  muscle-exercise  the  faradic  is  indicated. 

24.  Radiotherapy. — The  value  of  radiotherapy  as  a  therapeutic 
method  has  been  constantly  coming  into  increasing  prominence.  Al- 
though its  field  is  as  yet  limited,  it  has  established  its  value  in  such, 
conditions  as  some  forms  of  splenic  hypertrophy,  notably  leukemia;  en- 
largement of  the  thyroid  and  thymus  glands;  cervical  and  tracheo-bron- 
chial  adenitis;  and  in  eczema,  tinea  tonsurans,  nevi,  and  other  affections 
of  the  skin. 

25.  Climatotherapy. — It  is  a  matter  of  everyday  experience  that 
the  cure  or  relief  of  many  diseased  conditions  will  be  accomplished  more 
surely  and  promptly  by  change  of  climate  than  in  any  other  way.  Chil- 
dren with  subacute  bronchitis  often  react  quickly  to  such  a  procedure. 
Asthma,  pertussis,  chronic  or  recurring  rheumatism,  chronic  nephritis, 
tuberculosis,  anemia,  a  debilitated  state  of  the  general  or  the  nervous 
system,  and  slow  convalescence  from  many  acute  diseases,  are  all  aided 
bj'  it.  The  choice  of  locality  is  to  be  made  carefully.  A  fuller  discussion 
isi'out  of  place  in  this  connection,  and  reference  may  be  made  to  works 
upon  Climatology.  Here  it  may  be  said  only  that  many  of  the  good 
effects  of  change  of  climate  can  be  obtained  by  a  more  careful  regulation 
of  the  hygiene  at  home,  particularly  in  the  matter  of  obtaining  sufficient 
fresh  air  in  the  living  rooms,  both  by  day  and  by  night,  a  life  largely  in 
the  open  air,  and  the  guarding  against  overheating  from  too  great  warmth 
of  the  clothing. 

1  Keating,  Cyclopedia  of  the  Diseases  of  Children,  1890,  IV,  301. 


DIVISION  II 
DISEASES 

SECTION  I 

DISEASES  OF  THE  NEW  BORN 

Monsters  and  similar  malformations  arise  during  embryonal  life,  that 
is,  through  the  first  2  lunar  months.  They  are  the  products  of  defective 
development  rather  than  of  disease  and  are  properly  considered  in  works 
on  teratology  rather  than  on  pediatrics.  Some  of  them  will  be  briefly 
mentioned  in  other  sections.  Certain  of  the  diseases  of  the  fetus;  i.e. 
developing  during  the  last  8  lunar  months  of  intra-uterine  life,  continue 
as  diseases  of  the  new  born,  since  the  pathology  is  the  same  for  both 
periods  of  life.  Others,  however,  seem  incompatible  with  the  continu- 
ance of  life  outside  the  uterus  and  cannot  properly  be  considered  at  any 
length  in  works  treating  of  the  diseases  of  infants  and  children.  Conse- 
quently, any  grouping  of  Diseases  of  the  New  born  is  at  best  artificial 
and  incomplete,  and  only  to  be  excused  by  the  greater  convenience  for 
study  which  it  offers.  In  the  following  pages,  therefore,  are  considered 
chiefly  (1)  some  of  those  diseases  of  fetal  life  which  are  capable  of  con- 
tinuing, at  least  at  times,  in  the  living  child  at  birth,  and  (2)  certain  affec- 
tions which  are  peculiarly  liable  to  be  acquired  by  the  new-born  child  or 
are  witnessed  only  at  this  time.  There  are  excluded  from  this  section  or 
mentioned  only  briefly  (1)  numerous  diseases  of  the  new  born  which  are 
more  conveniently  treated  of  later,  (2)  diseases  limited  to  fetal  life  and 
not  seen  in  the  living  infant;  and  (3)  most  instances  of  defective  embryo- 
nal development;  i.e.  matters  pertaining  to  malformations  and  to 
teratology  in  general. 


251 


CHAPTER  I 
PREMATURE  INFANTS 

Etiology. — The  frequency  of  premature  birth  varies  to  some  extent 
with  the  locaht}^  and  the  influence  of  attendant  circumstances.  There 
is  a  range  of  from  5  to  25  per  cent,  according  to  the  statistics  of  institu- 
tions, as  pubUshed  by  Rommel. '^  An  average  might  be  fairly  assumed  as 
9  per  cent,  of  the  total  births  (Schauta).-  After  the  38th  week  of  intra- 
uterine life  the  infant  can  no  longer  be  called  premature,  inasmuch  as  it  is 
then  perfectly  developed  to  all  intents.  In  the  absence  of  actual  knowl- 
edge of  the  duration  of  the  pregnancy,  the  existence  of  prematurity  must 
be  determined  according  to  somewhat  arbitrary  standards.  In  general  it' 
is  assumed  that  a  birth- weight  of  less  than  2500  grams  (5.51  lb.)  or 
a  length  of  less  than  45  cm.  (17.72  inches)  is  an  indication  that  the  child 
is  probably  premature.  Yet  there  is  a  great  variation  in  the  weight  of 
premature  infants,  similar  to  that  seen  in  those  born  at  full  term;  and 
the  criterion  of  length  is  decidedly  more  reliable,  although  even  this  is 
not  entirely  to  be  depended  upon. 

A  distinction  is  to  be  made  between  cases  of  congenital  asthenia  and. 
those  of  premature  birth.  The  latter,  it  is  true,  generally  exhibit  debility, 
but  not  necessarily  so;  whereas  the  child  with  congenital  debility  born 
at  full  term  may  present  many  of  the  evidences  of  imperfect  development 
characteristic  of  the  prematurely  born.  The  distinction,  therefore, 
cannot  always  be  made  clinically  with  clearness. 

Among  the  causes  of  premature  birth  are  especially  conditions  affect- 
ing the  mother.  Syphilis  is  probably  chief  of  these,  but  acute  infectious 
disorders,  pneumonia,  nephritis,  tuloerculosis  and  diseases  of  the  heart 
occupy  a  prominent  etiological  position,  as  do  violent  exercise  and  trauma. 
Twin  births  are  very  likely  to  be  premature.  Miller-*  finding  prematurity 
in  60.6  per  cent,  of  3380  twin  births.  These  estimates  were,  however, 
based  upon  the  size  and  weight  of  the  infants,  which  are  less  applicable 
to  twins  than  to  single  births. 

Characteristics  at  Different  Periods  of  Intra=uterine  Life. — 
A  brief  description  may  be  given  of  the  characteristics  of  the  infant  born 
prematurely  after  different  periods  of  intra-uterine  life  which  are  com- 
patible with  at  least  temporary  viability.  The  appearances  at  earlier 
periods  than  these  have  no  bearing  upon  pediatrics.  The  lengths  and 
weights  of  the  body  are  those  given  bj^  Ballentyne.^  The  months  are 
calendar  months: 

At  24  weeks  (53^^  months),  the  fetus  measures  from  28  to  34  cm. 
(11  to  13.4  inches)  in  length  and  weighs  676  grams  (1.49  lb.).  There  is 
a  large  amount  of  lanugo,  the  skin  is  wrinkled  and  the  vernix  caseosa  is 
present.  The  eyebrows  and  lashes  are  evident.  The  deposit  of  subcu- 
taneous fat  has  only  just  commenced.  The  testicles  have  descended  to 
the  internal  inguinal  ring.     The  eyelids  have  become  separated. 

^  Pfaundler  und  Schlossmann,  Handb.  der  Kinderheilk.,  1906,  I,  2,  492. 
^Eulenberg's  Real  Encyclopiidie,  VIII,  120. 
3  Jahrb.  f.  Kinderheilk.,  1886,  XXV,  181. 
*  Antenatal  Pathol.,  1902,  77. 

252 


I 


PREMATURE  INFANTS  253 

At  the  close  of  28  weeks  (63^^  months),  the  fetus  measures  about  38 
cm.  (15  inches)  in  length  and  averages  a  weight  of  1170  grams  (2.58  lb.). 
The  whole  body,  except  the  palms  and  soles,  is  covered  with  lanugo  and  the 
vernix  caseosa  is  present.  The  hair  on  the  head  is  about  0.5  cm.  (0.2 
inch)  in  length.  The  skin  is  dull-reddish  and  somewhat  wrinkled.  There 
is  little  subcutaneous  fat.  The  pupillary  membrane  which  had  previously 
covered  the  pupil  has  commenced  to  disappear.  jMeconium  is  found 
in  the  intestine.     The  testicles  have  nearly  or  quite  descended. 

At  the  age  of  32  weeks  {7\^  months)  of  intra-uterine  life,  the  pre- 
maturely born  child  measures  from  39  to  41  cm.  (15.4  to  16.1  inches) 
and  weighs  1571  grams  (3.46  lb.).  The  lanugo  has  diminished  on 
the  body  and  the  hair  increased  on  the  scalp.  The  skin  is  still  dark-red 
and  wrinkled,  although  there  is  more  subcutaneous  fat  than  before. 
The  nails  are  harder  and  horizontal,  but  do  not  project  beyond  the  ends 


Fig.  42. — Premature  Infant. 
Born  at  6^-2  to  7  months;  weight  on  admission  to  the  Children's  Hospital  of  Phila- 
delphia when  10  days  old  2  pounds,  8  ounces  (227).     The  size  of  the  infant  can  be  estimated 
by  comparison  with  the  8-ounce  nursing-bottle. 

of  the  fingers.  The  pupillary  membrane  has  disappeared.  The  testicles 
have  fully  descended.  The  infant  is  very  feeble,  of  low  body-tem- 
perature, hardly  opens  the  eyes,  and  cannot  suck. 

At  the  age  of  36  weeks  (8>^  months),  the  fetus  measures  42  to  44 
cm.  (16.5  to  17.3  inches)  and  weighs  1942  grains  (4.28  lb.).  The  sub- 
cutaneous fat  has  very  decidedly  increascMl  and  the  wrinkhng  of  the  skin 
is  much  less,  while  the  face  is  more  rounded.  The  lanugo  has  largely 
disappeared.  The  deep-red  color  of  the  skin  is  now  found  only  on  the 
genitals.  The  hair  on  the  scalp  is  over  1  cm.  (0.39  inch)  in  length. 
The  nails  do  not  reach  the  finger  tips.  Children  born  at  tiiis  period 
should  live  under  careful  attention. 

General  Symptoms. — The  general  symptoms  characteristic  of 
prematurity  vary  with  the  duration  of  the  period  of  intra-uterine  life. 
In  tyi)ical  cases  the  cry  is  feeble  and  infrequent;  the  body-temperature 
is  low  and  maintained  at  the  normal  only  with  difliculty;  the  infant 
moves  its  limbs  but  little  and  lies  most  of  the  time  in  an  inactive  torpid 
state;  there  is  a  great  tendency  to  atelectasis  and  consequcMit  cyanosis 
which  recur  readily  after  temporary  successful  treatment;  the  skin 
IS  often  icteric  and  red,  or  pale,  or  cyanotic;  the  respiration  is  markedly 


254  THE  DISEASES  OF  CHILDREN 

irregular,  feeble  and  intermittent;  the  power  to  suck  is  often  absent, 
and  swallowing  is  slow.  Inasmuch  as  the  infant  was  born  before  its 
natural  time,  all  the  organs  are  in  an  imperfectly  developed  state. 

Course  and  Prognosis.  —  Even  with  successful  treatment  the 
progress  is  slow;  repeated  relapses  into  atelectasis  are  prone  to  occur; 
convulsions  and  pneumonia  are  liable  to  develop;  the  danger  of  infection 
is  decided;  the  digestion  is  often  feeble;  a  toxic  condition  often  develops; 
there  is  constant  difficulty  in  maintaining  the  body-temperature,  and 
the  occurrence  of  any  chilling  may  be  followed  by  fatal  results;  the  gain 

in  weight  is  slow;  and   hemorrhage   within 
the    cranium    and    elsewhere    takes    place 
readily.     Other    things     being    equal,    the    ' 
chance  of  living   depends  upon  how  early 
the   special    care    required    is   commenced,    ' 
and  the  skill  with  which  this  is  conducted,    i 
In   addition  to  this,   and  very  largely,  the    i 
prognosis  for  final  recovery  is  determined  by    ; 
the  intra-uterine  age.     A  child  born  at  the    \ 
end  of  24  weeks  usually  dies  in  a  few  hours. 
At  the  close  of  28  weeks,  recovery  occurs  in    i 
about  half  of  the  cases  with  sufficient  care.    ! 
At  the  end  of  the  32d  week  the  majority  of    ; 
Fig.  43.— Premature  Infant,    the  infants  will  live  with  proper  attention.    : 
Same  case  as  in  Fig.  42.    Now    The    Statistics  of    PoteP  are  interesting  in-    '■. 
aged   6   months.    Weight   7    ^his    connection.     They  are   shown  in  the 

pounds,  10  ounces.  r   n        •         j    i  i 

folio wmg  table: 
Table  68. — Viability  of   Premature  Infants  ] 

Per  cent.  : 

56  infants  born  at  6J-^  fetal  months;  45  died  =80.4  i 

131  infants  born  at  7      fetal  months;  76  died  =58.1  \ 

53  infants  born  at  73^  fetal  months;  17  died  =30.1  | 

110  infants  born  at  8      fetal  months;  39  died  =  35.5  ] 

i 
Only  1  case  survived  out  of  26  born  at  the  end  of  the  6th  fetal  month. 
A  few  cases  are  reported  in  medical  literature  of  survival  at  even  earlier     : 
periods,   as,  for  instance,   those   recorded   by  Smyth    (21  weeks)   and     I 
Barker  (23  weeks). 2  j 

As  already  stated,  the  weight  alone  is  not  a  safe  prognostic  guide,  j 
since  it  by  no  means  always  corresponds  with  the  actual  intra-uterine  '■■ 
age  of  the  child.  Some  remarkable  instances  of  recovery  are  on  record  ! 
in  infants  with  unusually  small  birth- weights;  as,  for  example,  the  case  j 
reported  by  Mansell^  in  which  the  baby  weighed  18  oz.  (510)  at  birth  1 
and  survived,  and  that  by  Bonnaire*  of  an  infant  weighing  820  grams  j 
(28.8  oz.) .  The  length  of  the  infant  is  a  better  prognostic  guide,  especially  | 
as  the  intra-uterine  age  is  often  difficult  to  determine  with  accuracy.  '< 
OstreiP  gives  the  following  serviceable  table :  4 


I 


1  Th^e  de  Paris,  1895.     Ref.  Delestre,  Th^e  de  Paris,  1901.  ^ 

■  Ref.  Kleinwachter  in  Eulenberg's  Real  Encyclopadie,  VIII,  60.  * 

3  Brit.  Med.  Journ.,  1902,  I,  773.  ] 

*  Bull.  soc.  de  m6d.  legale  de  France,  1912.     Ref.  Arch.  f.  Kinderh.,  1913,  LIX,  ^ 
213 

6  Monatsschr.  f.  Geburtsh.  und  Gynak.,  1905,  XXII,  45. 


PREMATURE  INFANTS 


255 


Table  69. — Vi.^bility  of  Premature  Ixfants 

40  cm.  (15.8  inches)  Chances  of  living  21  per  cent. 

41  cm.  (16.1  inches)  Chances  of  living  20 

42  cm.  (16.5  inches)  Chances  of  living  25 

43  cm.  (16.9  inches)  Chances  of  living  28 

44  cm.  (17.3  inches)  Chances  of  living  51 

45  cm.  (17.7  inches)  Chances  of  living  50 

46  cm.  (18.1  inches)  Chances  of  living  55 

47  cm.  (18.5  inches)  Chances  of  living  58 

The  large  majority  of  deaths  occur  in  the  first  weeks.  The  premature 
infant,  otherwise  healthy,  which  survives  will  develop  as  well  in  later 
years  as  the  one  born  at  full  term. 

Treatment. — Among  the  principal  difficulties  in  the  treatment  of 
premature  infants  are  the  maintenance  of  the  body-temperature; feeding; 
the  control  of  imperfect  respiration;  and  the  avoidance  of  infection.     For 


ii(,.      11. Beu   IOK   Pitl'-MATURK  InFANT. 

Iron  framework  covered  with  asbestos-board.     Cover    thrown  back, 
bottom  showing  electric  lamps. 


Door  open  at 


many  years  the  accomplishing  of  the  first  of  these  was  attempted  by  the 
employment  of  an  incubator,  and  numerous  forms  have  been  devised.  In 
all  the  effort  is  made  to  maintain  the  temperature  automatically  at 
a  fixed  degree,  and  to  supply  abundant  warm,  fresh,  moist  air.  The 
difficulties  attending  this  successful  ventilation  are  so  great  that,  on  the 
whole,  incubators  have  been  found  unsatisfactory  even  in  practise  in 
institutions.  A  much  better  plan  is  to  have  a  room  set  apart  for  the 
purpose,  in  which  the  temperature  is  kept  at  from  85°  to  90°F.  (20.4°  to 
32.2°C.)  and  fresh  warm  air  constantly  supplied. 

In  institutions  where  no  such  room  is  available,  as  well  as  in  private 
practice,  very  good  results  may  be  obtained  in  other  ways,  if  sufficient 
intelligent  attention  is  given.  A  lined  clothes-lja.sket  or  an  infant's 
metal  bath-tui)  may  be  partially  filled  with  ubs()rl)(Mit  cotton  and  the 
child  placed  in  this  after  having  been  oiled  and  wrapped  in  warmed  cotton 
and  then  in  blankets.  Hot  water-l)ottles  are  concealed  in  the  cotton  in 
the  tub,  close  to  but  not  touching  the  infant.     A  thermometer  in  the 


256 


THE  DISEASES  OF  CHILDREN 


cotton  shows  the  temperature  attained  here.  It  should  range  from  85°  to 
95°F.  (29.4°  to  35°C.),  and  must  be  carefully  watched,  as  otherwise  the 
infant's  temperature  may  readily  become  too  high.  The  bottles  should 
be  refilled  with  hot  water  as  needed,  but  not  all  of  these  at  the  same  time, 
in  order  to  keep  the  temperature  of  the  bed  as  uniform  as  possible. 
Electric  warming  pads  are  theoretically  excellent  but  practically  not 
without  danger,  as  a  short  circuit  may  develop  and  the  bed-clothing 
be  burned.  I  have,  however,  used  them  with  decided  satisfaction. 
A  very  serviceable  device  consists  of  a  box-like  crib  of  asbestos  card- 
board or  of  metal,  with  an  upper  and  a  lower  compartment.  In  the 
lower  a  series  of  electric  lamps  are  installed,  and  any  number  desired 
turned  on  to  produce  the  required  heat  in  the  bed.  In 
the  upper  compartment  is  placed  a  thin  mattress  or  a 
blanket,  and  over  this  cotton,  and  the  infant  enveloped  as 
already  described.  Perforations  in  the  partition  between 
the  compartments  allows  the  heated  air  to  rise.  A  sheet 
or  blanket  should  be  suspended  on  a  support  over  the. 
upper  end  of  the  bed  to  cut  off  excessive  light  and  any 
draughts.  I  have  used  a  device  of  this  nature  with  success 
at  the  Children's  Hospital  of  Philadelphia  (Fig.  44). 
The  room  in  which  the  infant  is  kept  should  receive  an 
abundance  of  fresh,  clean,  moistened,  warm  air,  and  the 
room-temperature  maintained  at  80°F.  (26.7°C.)  or  some- 
times over  this.  The  infant  should  have  no  clothing  what- 
ever, and  the  cotton  be  arranged  to  cover  the  whole 
body  except  the  head.  A  diaper,  or  an  extra  layer  of 
absorbent  cotton,  should  be  laid  under  the  nates.  In 
changing  this,  and,  in  fact,  under  all  circumstances,  the  child 
must  be  handled  or  exposed  as  little  as  possible.  Unless 
strong  enough  to  nurse  from  the  breast,  it  is  not  necessary 
to  remove  it  from  the  receptacle  even  for  feeding,  but  a 
frequent  change  of  position  in  bed  is  important.  Bathing 
should  not  be  employed  at  all,  unless  it  be  hot  baths  as 
needed  for  the  relief  of  atelectasis.  Once  a  day  the  child 
may    be  rubbed  all  over  with  warm  sweet  oil.     After  an 

Fig.  45. evacuation   of  the  bowels  or   bladder  the  nates  may  be 

Breck  Feeder,  cleansed  with  cotton  and  warm  oil.  The  infant's  rectal 
temperature  should  be  taken  every  few  hours,  and  an  effort 
made  to  keep  it  at  over  98°F.  (3G.7°C.).  When  it  is  found  that  the 
temperature  is  maintained  without  artificial  heating,  this  may  be  gradually 
abandoned,  and  the  child  dressed  in  the  ordinary  manner. 

The  best  food  by  all  odds,  however,  is  a  suitable  breast-milk.  In 
fact  this  is  usually  the  only  food  with  which  satisfactory  results  can 
be  obtained.  The  infant  may  nurse  from  the  breast  when  it  has  the 
power  to  suck.  If  it  has  not,  the  milk  may  be  pumped  from  the  breast 
and  given  in  a  medicine  dropper  or  the  Breck  feeder  (Fig.  45),  the  infant 
not  being  removed  from  the  bed.  It  is  often  best  to  dilute  the  milk 
}'2  with  water.  When  there  appears  to  be  difficulty  in  swallowing 
gavage  may  be  employed.  As  soon  as  the  infant  is  able  to  suck,  feeding 
should  be  directly  from  the  breast,  if  possible. 

In  the  cases  where  substitute  feeding  is  absolutely  unavoidable,  it 
is  necessary  to  determine  what  artificial  food  will  answer  best.  Its 
strength  in  all  the  elements  must  be  very  weak  at  first,  since  the  power  of 
digestion  is  but  feeble.     The  direction  in  which  an  increase  in  the  strength 


PREMATURE  INFANTS  257 

of  the  food  shall  be  made  can  be  determined  only  by  observing  the  results 
upon  digestion,  as  shown  by  the  character  of  the  stools,  the  frequency 
of  vomiting,  and  the  like.  According  to  the  individual  case  we  may  em- 
ploy whey-mixtures,  buttermilk,  food  consisting  chiefly  of  dextrin- 
maltose,  or  peptonized  milk.  It  would  seem  best  to  have  the  percentage 
of  fat  low  at  first  and  to  increase  it  with  great  caution.  As  soon  as  needed 
the  strength  of  the  food  in  general  and  the  amount  given  may  be  increased; 
but  with  care  against  over-feeding.  The  infant  should  be  weighed  daily, 
guarding  against  chilling  by  exposure,  since  it  is  principally  by  the 
weight  and  the  general  satisfactory  appearance  that  we  can  determine 
that  it  is  thriving.  Failure  to  gain  properlj'^  may  mean  that  more  food  is 
required.  Sometimes,  if  there  is  indigestion,  it  may  be  an  indication  to 
reduce  the  amount. 

Regarding  the  amount  of  food  needed  and  the  frequency  of  adminis- 
tration, there  can  be  no  absolute  rule.  The  caloric  needs  of  the  premature 
infant  are  probably  from  110  to  130  calories  per  kilogram  (50  to  59  per 
lb.)  daily,  exceeding  those  of  the  full-term  child.  This  is  the  result  of 
the  greater  body-surface  as  compared  with  the  body-weight.  This  does 
not  apply,  however,  to  the  1st  week,  and  perhaps  not  until  1  or  2  weeks 
have  passed.  Indeed  in  the  first  2  or  3  days  we  may  well  be  content  with 
a  sugar-solution.  Benedict  and  Talbot^  estimate  that  the  energy  re- 
quirements of  the  full-term  infant  during  the  first  6  days  are  only  62 
calories  per  kilogram  (28  per  lb.).  It  is  probable  that  the  premature 
infant  requires  no  more  or  even  less  than  this  during  this  period.  The 
amount  of  nourishment  taken  in  the  early  weeks  is  very  small,  varying 
with  the  weight  of  the  premature  infant  (125  to  345  c.c.  (4.23  to  11.67 
fl.oz.)  in  the  first  10  days.  Delestre).^  The  best  plan  is  to  calculate  the 
number  of  calories  probably  required,  and  to  give  a  daily  amount  of  food 
which  will  supply  these;  using  the  calculation,  however,  only  as  a  guide, 
and  allowing  especially  the  progress  of  the  infant  in  weight  and  the  condi- 
tion of  its  digestion  to  determine  the  increase.  The  frequency  of  feeding 
is  to  be  based  upon  the  amount  which  the  infant  can  take  and  retain  at 
a  time.  If  it  refuses  to  swallow  more  than  2  or  3  drams  (7  or  11),  or 
vomits  if  more  is  forced  upon  it,  feeding  every  1  to  2  hours  may  be  neces- 
sary. If  it  can  ingest  a  proper  amount  at  one  time,  intervals  of  23^^  to  3 
hours  will  be  chosen.  In  general  we  may  aim  for  a  quantity  of  from  ^-^ 
to  2  ounces  (15  to  57)  every  2}^^  to  3  hours  in  the  early  weeks,  depend- 
ing upon  the  weight,  length,  and  age  of  the  infant.  Vomiting  resulting 
from  the  administration  of  too  much  food  is  to  be  avoided  as  far  as 
possible,  on  account  of  the  danger  of  the  regurgitated  milk  entering  the 
respiratory  passages  and  producing  asphyxia  or  aspiration-pneumonia. 

The  treatment  of  the  premature  infant  is  in  other  respects  sympto- 
matic. The  relief  of  atelectasis  and  cyanosis  is  to  be  obtained  by  reflex 
stimulation,  as  by  plunging  into  a  hot  bath  of  100  to  105°F.  (37.8°  to 
40.()°C.),  preferably  containing  mustard,  in  order  to  produce  crying. 
The  inhalation  of  oxygen  is  often  of  service,  and  a  retort  of  the  gas  should 
be  close  at  hand  for  immediate  use  when  required.  Infection  is  to  be 
very  carefully  avoided,  especially  by  great  attention  to  the  care  of  the 
navel,  and  tlie  employment  of  sterile  water  for  any  washing  necessary. 

1  Carnegie  In«tit,  Wasli.,  1915,  233.  Ref.  Editorial,  Jouni.  Anicr.  Med.  .Vssoc, 
1916,  LXVl,  14()(i. 

^Th^e  de  Pari.s,  1901. 


17 


258  THE  DISEASES  OF  CHILDREN 

CHAPTER  II 
SEPSIS  IN  THE  NEW  BORN 

The  septic  infections  of  the  new  born  include  a  number  of  conditions 
which  clearly  are  due  to  the  entrance  of  pyogenic  germs  into  the  organism. 
Many  of  these  exhibit  also  such  special  peculiarities  or  localization  that 
they  may  be  described  as  distinct  diseases.  Still  others  are  possibly 
septic,  yet  are  of  an  origin  not  clearly  understood.  General  septic  in- 
fection as  it  occurs  in  the  new  born  is  the  topic  now  under  consideration. 

Etiology  and  Pathological  Anatomy. — Sepsis  is  still  too  common, 
but  its  frequency  is  trifling  as  compared  with  the  former  extreme  preva- 
lence of  the  affection.  In  rare  instances  septic  infection  may  take  place 
before  birth.  In  this  event  the  fetus  generally  is  born  dead.  The  cause 
in  such  cases  may  be  a  penetration  of  bacteria  or  of  toxic  substances 
from  the  mother  through  the  placenta,  the  mother  herself  being  ill,  often 
with  sepsis.  In  some  instances  the  infection  is  through  the.  amniotic 
fluid,  in  not  a  small  number  of  cases  depending  upon  a  maternal  peri- 
typhilitic  inflammation  (Hellendall).^  In  sepsis  acquired  in  this  way  the 
primary  lesion  is  a  pneumonia.  More  often  sepsis  develops  through 
injuries  received  during  or  after  birth,  as  through  abrasions  of  the  skin  or 
by  the  entrance  of  septic  matter  derived  from  the  discharges  of  the  mother 
into  the  mouth,  stomach,  rectum,  vagina  or  lungs  of  the  infant.  The 
water  used  for  washing  the  infant  may  be  the  source  of  the  infection. 
Operations  performed  on  the  new  born,  such,  for  instance,  as  circumcision, 
the  opening  of  a  cephalhematoma  or  the  incision  of  the  frenulum  linguae 
for  tongue-tie  may  serve  as  portals  of  entry.  Although  the  possibility  of 
the  development  of  sepsis  through  such  sources  is  to  be  recognized,  in  the 
great  majority  of  instances  it  starts  at  the  umbilicus,  beginning  oftenest 
before  complete  separation  of  the  cord,  and  is  first  manifested  by  an 
umbilical  arteritis.  In  340  autopsies  in  new-born  infants  Runge^  found 
36  cases  of  general  sepsis.  In  30  of  these  infection  could  be  traced  to  the 
navel,  and  in  all  of  these  umbilical  arteritis  was  present.  The  fact  that 
the  umbilical  wound  is  healed  is  no  proof  that  infection  of  the  umbilical 
vessels  does  not  exist. 

Beginning  at  the  portal  of  entry,  wherever  this  may  be,  the  infection 
may  either  remain  local,  or  may  become  more  general,  there  occurring 
in  the  new  born  but  little  protecting  lymphadenitis  to  prevent  this;  or 
general  septic  infection  may  occasionally  take  place  without  the  portal 
of  entry  showing  anything  abnormal  or  even  being  discoverable.  If  the 
sepsis  is  local  only,  there  may  be  produced  phlegmonous  inflammation 
of  the  injured  skin  of  various  parts  of  the  body,  mammitis,  omphalitis, 
thrombosis  of  the  umbilical  arteries  or  vein,  stomatitis,  rhinitis,  etc.;  or 
in  cases  of  aspiration  of  an  infectious  fluid,  septic  pneumonia.  If  the 
process  extends  from  one  of  these  portals  of  entry  the  sepsis  may  involve 
almost  any  of  the  more  distant  parts  of  the  body. 

In  infants  still-born  or  dying  very  shortly  after  birth,  the  subjects  of 
intra-uterine  infection,  there  is  found  macerated  skin,  petechise  on  the 
surface  of  the  body  and  on  the  serous  membranes,  bloody  or  serous  effu- 
sions into  the  serous  cavities,  and  smaller  or  larger  extravasation;?  of  blood 

1  Beitrage  z.  Geburtsh.  u.  Gyniik.,  1906,  X,  320. 
-  Krankh.  d.  ersten  Lebenstagen,  1893,  136. 


SEPSIS  IN  THE  NEW  BORN  259 

into  and  fatty  degeneration  of  the  internal  organs.  In  those  acquiring 
the  disease  after  birth  there  is  the  same  tendency  to  fatty  degeneration 
of  and  hemorrhages  into  the  internal  organs,  with  petechiae  of  the  serous 
membranes,  and  bloody,  serous,  or  purulent  effusions  into  the  serous 
cavities.  There  are  also  various  lesions  of  different  organs,  depending 
upon  the  localization  of  the  septic  process.  Septic  thrombi  are  frequent, 
especially  of  the  umbilical  arteries.  Inflammation  or  hemorrhage  of  the 
brain  or  meninges  is  also  common,  as  are  cutaneous  or  subcutaneous 
abscesses,  peritonitis,  pericarditis,  pneumonia  and  pleurisy.  Miiller^ 
regards  peritonitis  as  one  of  the  frequently  observed  localizations  in 
general  septic  infection.  Bednar-  found  croupous  pneumonia  15  times 
and  pleurisy  10  times  in  the  autopsies  on  87  cases  of  sepsis.  Runge^ 
recorded  pneumonia  in  21  out  of  55  cases  of  sepsis  of  umbilical  origin. 
Involvement  of  the  digestive  apparatus  is  frequent.  Osteomyelitis, 
arthritis,  nephritis,  pyelitis,  and  otitis  are  often  observed. 

The  ultimate  cause  of  the  pyogenic  infection  appears  to  be  chiefly 
varieties  of  the  staphylococcus  and  streptococcus.  The  pneumococcus, 
colon  bacillus,  bacillus  pyocyaneus,  gonococcus  and  others  are  also  fac- 
tors in  some  instances.  The  germs,  as  stated,  are  acquired  in  many  ways. 
The  vaginal  discharges  are  a  fruitful  starting  point  for  the  cases  de- 
veloped during  birth.  Later  there  is  no  dearth  of  sources  from  which 
infection  can  arise,  all  depending  upon  lack  of  aseptic  cleanliness  of  some 
form.  All  new-born  infants  are  prone  to  the  development  of  the  disease, 
but  it  is  particularly  common  among  those  born  in  institutions,  since  the 
dangers  of  infection  are  greater  there.  It  is  disputed  whether  infection 
may  take  place  through  the  milk  of  the  mother. 

Symptoms. — The  symptoms  usually  appear  either  immediately 
after  birth  or  at  some  time  within  the  fiufst  10  days.  They  vary  greatly, 
depending  upon  the  seat  of  the  lesions.  As  a  rule,  however,  in  general 
septic  infection  there  is  great  and  characteristic  depression  of  strength 
with  rapid  loss  of  weight  and  entire  anorexia.  Fever  is  irregular.  It  is 
generally  present  at  the  onset  and  frequently  high,  butfmay  be  absent 
throughout  and  the  temperature  is  often  subnormal  toward  the  end. 
Severe  diarrhea  is  a  common  symptom;  vomiting  may  occur;  icterus 
is  frequent  and  often  intense,  or  the  skin  may  be  of  a  pale-grey  tint,  and 
septic  erythemata  are  frequently  observed.  The  pulse  is  rapid  and  weak, 
the  respiration  irregular;  sometimes  deep  and  rapid.  The  occurrence  of 
small  or  larger  hemorrhages  in  different  parts  of  the  l^ody  is  a  common 
and  characteristic  symptom.  The  child  looks  ill,  is  usually  apathetic  or 
somnolent,  has  a  feeble  cry  and  sometimes  develops  the  symptoms  of 
collapse.  Various  nervous  symptoms  may  be  seen,  among  them  tossing, 
rolling  of  the  head,  hypertonic  states,  twitching  of  the  muscles,  tremor, 
and  sometimes  convulsions.  The  urine  generally  contains  albumin. 
Enlargement  of  the  spleen  may  sometimes  be  discovered.  The  coagula- 
tion-time of  the  blood  is  increased. 

When  the  disease  is  prolonged  the  symptoms  may  be  masked,  the 
principal  one  being  a  rapid,  continuous  losss  of  weight,  until  finally  the 
development  of  some  local  septic  process  makes  the  condition  clear. 
Naturally  in  many  instances  the  character  of  the  symptoms  is  modified 
by  the  development  of  those  of  localized  involvement  as  well. 

'  Gerhardt's  Handb.  d.  Kinderkr.,  1877,  II,  177. 
-  Kraiikhcit.  d.  Neugeb.  u.  Siiugling.,  IS50,  IV,  245. 
^  Loc.  cit.  95. 


260  THE  DISEASES  OF  CHILDREN 

Course  and  Prognosis. — Some  cases  run  a  rapid  course,  ending 
fatally  in  from  1  to  3  days.  Others  last  for  weeks;  but  in  all  the  prognosis 
is  very  unfavorable.  The  mildest  and  more  slowly  progressing  cases  may 
occasionally  recover,  but  this  is  certainly  unusual,  and  all  those  with  well- 
marked  symptoms  of  a  general  infection  terminate  fatality.  The  earlier 
the  infection  occurs  and  the  more  widespread  the  lesions,  the  worse  the 
prognosis. 

Diagnosis. — The  diagnosis  offers  no  difficulty  where  the  symptoms 
are  well  developed,  and  a  source  of  infection  can  be  recognized.  It  is  often 
impossible  when  no  portal  entry  can  be  found  wdiich  shows  evidence 
of  septic  infection,  or  unless  some  local  metastatic  manifestation  of  sepsis 
develops.  The  discovery  of  enlargement  of  the  spleen  is  corroborative 
but  not  positive  evidence.  The  absence  of  fever  does  not  exclude  sepsis, 
and  the  failure  of  a  leucocytosis  to  appear  is  not  conclusive.  The  only 
positive  evidence  may  be  the  discovery  of  septic  germs  in  the  blood. 

Treatment. — This  consists  principally  in  prophylaxis.  Every 
possible  source  of  infection  is  to  be  removed.  Should  the  mother  be  suf- 
fering from  puerperal  fever,  the  child  must  be  separated  absolutely  from 
her.  Any  discoverable  wound  upon  the  skin  or  mucous  membrane  of  the 
child  must  receive  as  careful  antiseptic  treatment  as  possible.  The 
umbilicus  (see  p.  72)  and  the  mouth  should  have  especial  attention. 
For  the  disease  when  once  developed  little  can  be  done,  except  the  em- 
ployment of  vigorous  stimulating  and  supporting  measures,  the  prevention 
of  shrinking  of  the  tissues  by  the  employment  of  hypodermoclysis,  and 
the  adoption  of  such  surgical  treatment  for  local  conditions  as  seems 
indicated. 

To  many  of  the  special  local  manifestations  of  septic  infections,  such 
as  omphalitis,  inflammation  of  the  umbilical  vessels,  mammitis,  some 
forms  of  hemorrhage,  and  the  like,  separate  consideration  will  be  given 
among  the  diseases  of  the  new  born.  Others,  such  as  pneumonia,  peri- 
tonitis, erysipelas,  etc.,  will  be  discussed  later  in  the  general  considera- 
tion of  these  disorders. 


CHAPTER  III 

ACUTE  FATTY  DEGENERATION  OF  THE  NEW  BORN 

(Buhl's  Disease) 

This  condition  was  first  described  by  Buhl  in  1861.^  Cases  have 
been  reported  by  a  few  others,  notably  Hecker-  and  Runge.'"' 

Etiology. — The  disease  is  a  very  uncommon  one,  or  at  least  seldom 
recognized  in  human  beings,  although  a  similar  condition  in  the  new  born 
of  animals  has  been  seen  more  frequently.  The  cause  is  entirely  unknown. 
Although  it  is  very  probable  that  it  is  of  a  septic  nature,  this  has  not 
been  proven,  and  has,  indeed,  been  strongly  contested.  In  a  typical 
case  described  by  Lucksch,*  colon  bacilh  were  found  in  the  blood.  The 
disease  occurs  in  isolated  cases  only,  and  has  been  seen  especially  in  well- 
developed    infants    who    have    been    born   much    asphyxiated    without 

1  Klinik  d.  Geburtsk.,  1861,  I,  296.     Ref.  Runge,  162. 

2  Arch.  f.  Gynak.,  1876,  X,  537. 

3  Krankh.  d.  ersten  Lebenst.,  1893,  162. 

■    "  Prag.  med.  Wochenschr.,  1913,  XXXVIII,  167. 


ACUTE  FATTY  DEGENERATION  OF  THE  NEW  BORN  261 

discoverable  cause,  and  have  continued  so  to  some  extent  in  spite  of 
treatment. 

Pathological  Anatomy. — The  body  is  cyanotic  and  frequently 
icteric  also.  The  skin  is  often  edematous  and  may  exhibit  hemorrhages. 
Effusions  of  blood,  either  ecchjanotic  in  character  or  in  large  amounts, 
are  found  in  nearly  all  the  internal  organs;  especially  from  or  in  the 
serous  membranes  of  the  brain,  the  pleura  and  pericardium,  the  endo- 
cardium, the  mediastinal  connective  tissue  and  the  peritoneum.  They 
also  occur  in  the  muscles,  the  thymus  gland,  and  most  of  the  mucous  mem- 
branes. The  brain  is  soft  and  congested;  the  lungs  often  contain  infarcts 
and  the  bronchi  bloody  mucus.  The  heart-muscle  is  firm  and  dark  red 
in  cases  dying  promptly;  pale  and  soft  in  those  of  longer  duration.  The 
spleen  is  generally  enlarged  and  very  soft.  The  liver  is  at  first  dark  red ; 
later  pale,  icteric  and  perhaps  slightly  enlarged.  The  stomach  and 
intestines  often  contain  effused  blood  and  there  are  hemorrhages  in  the 
mucous  membrane,  and  the  walls  are  thickened  and  edematous.  The 
kidneys  are'swollen  and  dark-red  in  the  early  stages,  but  later  pale  and 
yellowish.  They  exhibit  numerous  hemorrhages  into  their  substance, 
and  often  a  complete  choking  of  many  of  the  tubules  with  granular 
fatty  matter.  The  umbilicus  and  its  vessels  are  normal,  except  for  the 
evidences  of  the  presence  of  hemorrhage  which  has  occurred  from  it 
and  in  the  tissues  about  it. 

The  change  most  characteristic  of  the  disease  is  the  marked  fatty 
degeneration  of  the  liver,  heart,  kidnej'S  and  epithelium  of  the  pulmonary 
alveoli.  This  does  not  necessarily  involve  in  each  case  all  of  the  organs 
mentioned,  but  may  in  some  of  them  be  entirely  absent  or  be  replaced 
by  a  parenchj^matous  inflammation.  The  degenerative  lesions  are 
similar  to  those  produced  by  phosphorus-poisoning. 

•  Symptoms  and  Course. — The  asphyxia  with  which  these  children 
are  born  does  not  yield  to  treatment,  and  many  of  the  cases  die  promptly. 
If  life  is  maintained  longer  there  develops  diarrhea  often  with  bloody 
or  blackish  stools  (melena),  frequent  vomiting  of  blood,  and  hemorrhage 
from  the  navel  after  the  separation  of  the  cord,  this  being  generally 
in  small  amount,  but  sometimes  large  enough  to  be  fatal.  The  hemor- 
rhagic symptoms  appear  about  the  oth  day  of  life.  The  cj'anotic  color 
of  the  skin  persists,  becomes  combined  with  or  gives  place  to  icterus, 
and  edema  is  seen  in  some  instances.  Bleeding  may  occur  into  the 
skin  or  from  the  mucous  membrane  of  the  mouth  or  nose,  conjunctiva 
or  ear.  There  is  anemia,  great  prostration,  rapid  loss  of  weight,  and 
collapse.  Fever  is  absent  or  inconsiderable.  Not  always  are  all  the 
symptoms  present.  The  asphyxia  may  be  followed  by  sudden  death, 
or  may  in  some  cases  be  slight  at  first  and  then  may  increase  rapitily, 
accompanied  by  the  characteristic  symptoms.  In  some  instances  no 
external  hemorrhage  whatever  is  seen.  The  disease  may  last  but  a  few 
hours  before  the  fatal  ending  occurs.  It  rarely  continues  as  long  as  2 
weeks.  The  prognosis  is  entirely  unfavorable.  Whether  lighter  forms 
recover  cannot  1)(^  known,  since  in  these  the  determining  (Hagnostic 
feature,  the  fatty  degeneration,  is  ne(;essarily  undiscoverable. 

Diagnosis.- — ^An  absolute  diagnosis  is  impossible  except  l\y  micro- 
scopic examination  of  the  tissues.  Even  a  probal)le  diagnosis  is  difhcult 
unless  all  the  symptoms  are  present,  especially  the  combination  of  marked 
asphyxia  and  widc^spread  hemorrhage,  and  the  absence  of  any  umbilical 
disease.  The  disorder  resembles  closely  and  probably  is  identical  with 
some    forms  of  sepsis  of    the    new   ])orn.     Infectious    hemoglobineniia 


262  THE  DISEASES  OF  CHILDREN 

is  like  it  in  many  particulars,  but  is  distinguished  by  the  characteristic 
condition  of  the  urine  present  in  this  affection.  In  the  case  of  infants 
which  die  asphyxiated  soon  after  birth  it  is  impossible  to  determine 
without  autops}^  whether  acute  fatty  degeneration  was  not  the  disease 
present;  and  this  applies,  too,  to  those  born  little  or  not  at  all  asphyxiated, 
who  later  suddenly  develop  this  symptom  and  die  promptly.  The 
importance  of  the  microscopic  examination  in  all  doubtful  cases  is, 
therefore,  evident. 

The  treatment  can  be  only  sj-mptomatic,  efforts  being  directed  to  the 
sustaining  of  strength,  the  relief  of  the  asphyxia,  and  the  control  of  the 
hemorrhage. 


CHAPTER  IV 

ACUTE  INFECTIOUS  HEMOGLOBINEMIA  OF  THE  NEW  BORN 

(Winckel's  Disease;  Hemoglobinuria  neonatorum;  Cyanosis  afebrilis 
icterica  pemiciosa  cum  hemoglobinuria;  etc.) 

Although  WinckeP  recognized  the  existence  of  hemoglobinuria  as  &■ 
symptom  in  an  epidemic  affecting  23  children  in  the  Lying-in  Hospital 
of  Dresden,  yet  an  earlier  epidemic  in  which  10  children  were  attacked 
was  well  described  by  Bigelow  in  1875.^  A  condition  probably  the  same 
had  already  been  reported  by  Parrot^  and  by  Charrin*  in  1873,  and  still 
earlier  by  Pollack"  in  1871. 

Etiology. — The  affection  is  a  rare  one.  It  occurs  generally  in 
institutions  and  in  an  epidemic  form,  although  isolated  cases  have  oc- 
casionally been  reported,  and  it  attacks  well-developed  children  equally 
with  others.  It  appears  closely  aUied  both  to  the  septic  infection  and  to 
the  hemorrhagic  disease  of  the  new  born,  and  is  also  very  closely 
related  to  acute  fatty  degeneration  of  the  new  born  (p.  260).  That 
it  is  an  infection  seems  certain,  yet  the  nature  of  this  is  unknown; 
for  although  both  streptococci  and  colon  bacilli  have  been  reported,  these 
are  germs  commonly  found  in  sepsis,  which  is  without  any  such  char- 
acteristic group  of  symptoms.  That  it  is  not  produced  by  the  ingestion 
of  a  poison  was  proven  by  Winckel's  investigations. 

Pathological  Anatomy. — The  lesions  as  based  upon  Winckel's 
description  show  the  internal  organs  as  well  as  the  skin  cyanotic  and 
icteric  in  hue.  The  spleen  is  much  enlarged  and  hard,  of  a  blackish 
red  color,  and  contains  a  large  amount  of  brown  coloring  matter,  partly 
free,  partly  in  the  cells  of  the  pulp.  The  cortical  layer  of  the  kidney 
is  thicker  than  normal,  of  a  brownish  color,  and  exhibits  small 
hemorrhages.  The  pyramids  are  blackish-red  and  show  narrow  black 
streaks  converging  toward  the  papillse  and  due  to  the  deposit  of  hemo- 
globin in  the  canals.  The  bladder  contains  greenish-brown  urine. 
The  liver  is  enlarged;  the  mesenteric  glands  arud  Peyer's  patches  swollen. 
Punctate  hemorrhages  are  seen  in  most  of  the  organs  of  the  body,  as 
in  the  membranes  of  the  brain  and  spinal  cord,  under  the  serous  covering 

1  Deutsch.  med.  Wochenschr.,  1879.,  V,-303. 

2  Bost.  Med.  and  Surg.  Journ.,  1875,  March  11,  277. 
'  Arch,  de  phys.  norm,  et  path.,  1873,  512. 

*  These  de  Paris,  1873. 

5  Wien.  med.  Presse,  1871,  457. 


HEMORRHAGE  IN  THE  NEW  BORN  263 

of  the  liver,  and  especially  in  the  pleura,  endocardium  and  pericardium 
and  in  the  mucous  membrane  of  the  stomach  and  intestines.  There 
is  sometimes  a  fatty  degeneration  of  the  liver  and  heart-muscle.  The 
umbilical  vessels  are  nearly  always  normal.  Bacteria  of  any  sort  have 
usually  not  been  discovered. 

Symptoms. — The  disease  begins  usually  on  from  the  4th  to  the 
8th  day  of  life,  occasionally  earlier  or  later.  The  earliest  symptoms 
are  restlessness,  loss  of  appetite,  prostration,  and  intense  cyanotic 
discoloration  of  the  entire  surface.  Well-developed  icterus  is  promptly 
combined  with  this,  and  rapidly  increases  in  intensity  until  the  surface  is  of 
a  bronze  color.  The  temperature  is  normal  or  below,  rarely  slightly 
elevated.  The  respiration  is  generally  accelerated,  the  pulse  little  if  at  all 
altered.  The  urine  is  pale-brown  in  color  and  voided  frequently  in  small 
amounts  with  straining.  Examination  shows  the  presence  of  hemo- 
globin, granular  casts  and  renal  epithelium,  urate  of  ammonium,  micro- 
cocci, and  a  small  amount  of  albumin.  iSTo  bile  or  bihary  acids  are 
present  in  it.  The  stools  vary  in  color  from  dark-green  to  yellowish 
or  brown.  Vomiting  and  diarrhea  occur  occasionally.  On  incising  or 
scratching  the  skin  over  the  most  cyanotic  regions  a  thick,  syrupy 
fluid  of  a  blackish-brown  color  exudes,  but  only  on  firm  pressure.  The 
blood  shows  an  increase  in  the  number  of  leukocytes,  numerous  granules, 
and  a  great  diminution  in  the  number  and  increase  in  the  size  of  the  red 
blood-cells,  many  of  which  appear  to  have  lost  their  coloring  matter. 
Collapse  develops  with  great  rapidity;  there  is  somnolence,  and  con- 
vulsions are  hable  to  terminate  the  case. 

Prognosis. — This  is  most  unfavorable,  as  all  severe  cases  die. 
Only  2  of  Bigelow's  and  2  of  Pollock's  cases  recovered;  while  19 
of  Winckel's  23  cases  are  known  to  have  ended  fatally,  and  only  1  certainly 
to  have  recovered.  Ljwow^  reported  better  results,  4  out  of  7  cases  re- 
covering. Death  usually  occurs  in  a  few  hours  to  4  days,  generally  in 
2  days. 

Diagnosis. — The  disease  is  so  characteristic  that  mistakes  in  diagnosis 
can  hardly  be  made.  Although  it  resembles  strongly  in  some  respects 
acute  fatty  degeneration  of  the  new  born,  it  is  to  be  distinguished  by  the 
presence  of  hemoglobinuria  and  the  occurrence  usually  in  epidemics. 

The  treatment  can  be  only  symptomatic,  efforts  being  made  to  main- 
tain life  bv  stimulants  and  food. 


CHAPTER  V 
HEMORRHAGE  IN  THE  NEW  BORN 

Hemorrhages  at  this  early  period  of  life,  although  not  common,  are 
still  frequent  as  compared  with  their  presence  later  in  childhood.  They 
may  occur  in  different  parts  of  the  body  and  from  different  causes.  Those 
not  mentioned  here  will  be  found  in  other  chapters. 

Etiology .^ — ^The  previous  general  health  appears  to  have  no  constant 
influence,  for  while  some  of  the  infants  affected  have  previously  been  in 
poor  condition  others  appear  strong  and  hearty.  In  some  instances  the 
hemorrhages,  usually  single,  seem,  to  be  the  result  of  accident,  as  in  hema- 
toma of  the  scalp  (p.  209)  or  of  the  sternoclcideomastoid  (p.  272) ,  and 
in  some  cases  of  hemorrhage  from  the  umbilicus  (p.  292)  or  from  some 

'  Medicinskoje  Obosrenje,  1893,  No.  14.  Ref.  Jahrb.  f.  Kinderh.,  1S94,  XXX\'III, 
497. 


264  THE  DISEASES  OF  CHILDREN 

other  part  of  the  bod}^  as  a  result  of  trauma  received.  After  difficult 
and  prolonged  labor  various  visceral  hemorrhages  may  occur,  especially 
those  within  the  cranium.  Spencer^  concludes  from  150  autopsies  that 
the  use  of  the  forceps  is  a  common  producer  of  intracranial  hemorrhage. 
Premature  birth  is  another  cause  of  hemorrhage,  especially  within- the 
cranium.  Difficult  breech  presentations  are  more  prone  to  occasion 
hemorrhages  of  the  abdominal  viscera.  In  very  many  instances  the 
bleeding  depends  upon  septic  infection,  as  already  pointed  out,  and 
bacteria  of  various  sorts  have  been  found  in  the  blood.  (Seep.  259.)  In 
these  cases  the  hemorrhages  are  liable  to  be  widespread  and  of  small 
size.  In  others  special  hemorrhage-producing  bacteria  have  been  found 
(Schloss  and  Commiskey).-  Congenital  syphilis  appears  to  be  the  active 
agent  in  some  instances.  The  influence  of  this  factor  has  been  reviewed 
by  Hess^  and  by  Pontoppidan.^  Wilson'^  reported  hemorrhage  occurring 
in  45  of  3364  new-born  infants,  and  in  10  of  these  it  appeared  to  be  due  to 
congenital  syphilis.  In  many  others  we  are  ignorant  of  the  exact  etiology 
and  pathology,  although  the  presence  of  some  infection  or  toxemia  seems 
probable.  Either  the  resistance  of  the  blood-vessel  walls  is  weakened  in 
some  way,  or  the  blood  itself  is  altered.  Studies  made  by  Schloss  and 
Commiskey^  upon  the  coagulability  of  the  blood  in  10  cases  of  hemor- 
rhagic disease  found  this  diminished  in  some  instances,  but  unaltered  in 
others.  Many  of  the  forms  of  hemorrhage  will  be  referred  to  later  in 
discussing  the  diseases  of  the  organs  in  which  the  bleeding  occurs. 

Bleeding  which  takes  place  without  any  evidence  of  trauma  may  be 
called  "spontaneous."  Townsend^  has  applied  the  term  "The  hemor- 
rhagic disease  of  the  new  born"  to  the  condition  in  which  small  or  large 
effusions  of  blood  occur  simultaneously  in  many  different  parts  of  the 
body,  independent  of  any  discoverable  cause.  It  was  earlier  described 
by  Minot  in  1852.^  The  affection  appears  to  be  probably  of  an  infec- 
tious nature  and  self-limited,  most  of  the  non-fatal  cases  recovering  within 
a  week.  This  early  spontaneous  hemorrhage  is  quite  distinct  from 
hemophilia  (Vol.  II,  p.  474),  among  other  respects  in  that  the  tendency  of 
the  new  born  to  bleed  does  not  persist  if  the  child  survive.  Hemorrhage 
in  the  new  born  occurs  much  most  frequently  in  institutions.  Ritter' 
found  190  such  in  13,000  infants  in  the  Prague  Foundling  Hospital;  i.e. 
1.46  per  cent.,  and  Townsend^*^  32  cases  in  7225  births;  i.e.  0.44  per  cent. 
The  accident  occurs  much  the  most  frequently  in  the  1st  or  the  2d  week 
of  life.  Abt^^  estimates  that  from  1  in  500  to  1  in  700  institution-infants 
suffer  from  hemorrhage. 

Locality  of  the  Lesions.^ — ^The  regions  of  the  body  affected  are 
various  and  generally  are  multiple.  One  of  the  commonest  seats  is  the 
gastroenteric  tract.  In  Ritter's^^  190  cases  hemorrhage  occurred  from 
the  intestine  in  39,  the  mouth  in  28,  and  the  stomach  in  20.     (See  Melena, 

'  Trans.  Obst.  See,  Lond.,  1891,  XXXIII. 

^Amer.  Jour.  Dis.  Child.,  1911,  I,  276. 

^  Archives  of  Pediatrics,  1904,  XXI,  598.  ' 

*  Hospitalstidendo,  1916,  LIX,  626.     Ref.  Brit.  Jour.  Child.  Dis.,  1916,  XIII,  308. 

5  Archives  of  Pediatrics,  1905,  XXII,  43. 

«Amer.  Jour.  Dis.  Child.,  1912,  III,  216. 

7  Boston  Med.  and  Surg.  Jour.,  1891,  CXXV,  218;  Archives  of  Pediatrics,  1894, 
XI    559 

8  .\mer.  Jour.  Med.  Sci.,  1852,  XXIV,  310. 

9  Oesterreich.  Jahrb.  f.  Padiatrik,  1871,  I,  127. 
'oioc.  cit.,  218. 

1'  Jour,  Amer.  Med.  A.ssoc.,  1903,  XL,  284. 
'■^  Loc.  cit.,  159. 


HEMORRHAGE  IN   THE  NEW  BORN  265 

p.  266.)  The  flow  of  blood  is  generally  small,  but  is  often  in  larger  amount 
and  discharged  from  the  bowels  as  a  black,  tarry  substance.  Bleeding 
may  take  place  into  other  of  the  abdominal  organs,  due  generally  to 
difficult  labor  when  the  hemorrhage  is  single,  but  oftener  the  result  of  the 
hemorrhagic  disease,  sepsis,  or  other  causes  when  the  hemorrhage  is 
multiple.  Large  effusion  into  the  suprarenal  capsule  is  one  of  the  most  fre- 
quent forms  (Vol.  II,  p.  529).  Small  hemorrhages  under  the  peritoneum 
are  seen  not  infrequently.  Larger  ones  also  may  occur  here,  being  com- 
monly traumatic  in  origin.  These  and  especially  those  into  the  supra- 
renal bodies  may  burst  into  the  peritoneal  cavity  and  produce  sudden 
death  from  collapse.  In  some  such  instances  it  may  be  impossible  to 
discover  the  original  source.  Occasionally  bleeding  may  take  place  from 
the  liver  (Bonnaire  and  Durante).^  Intracranial  hemorrhage  is  one  of 
the  commoner  varieties.  In  33  autopsies  upon  infants  born  prematurely, 
Couvelaire^  found  the  brain  to  be  the  seat  of  hemorrhage  in  5  instances, 
excluding  cases  of  meningeal  and  intraventricular  bleeding.  The 
numerous  instances  of  cerebral  birth-palsy  are  generally  dependent  upon 
intracranial  bleeding.     (See  Cerebral  Palsy,  Vol.  II,  p.  365.) 

Small  hemorrhages  may  occur  upon  the  serous  covering  of  the  lungs. 
More  rarely  larger  ones  take  place  into  the  puhiionary  tissue,  the  bronchi, 
or  the  pleural  cavity.  Epistaxis  is  uncommon.  Small  effusions  of  blood 
may  be  found  in  the  thymus  gland.  Hemorrhage,  generally  in  small 
amount,  may  occasionally  arise  from  the  female  genitals.  Schukowski^ 
collected  only  35  cases  of  metrorrhagia  in  10,000  new-born  female  infants. 
(See  also  Vol.  II,  p.  230.)  Bleeding  from  the  bladder  or  kidneys  may  ex- 
ceptionally occur.  This  may  be  the  result  of  a  general  hemorrhagic 
disease  or  may  be  purely  traumatic  in  origin,  dependent  upon  the  pres- 
ence of  uric  acid  infarcts.  Hemorrhage  may  take  place  from  the  ears  or 
the  eyelids. 

Bleeding  from  the  umbihcus  is  the  most  common  variety,  132  (69.47 
per  cent.)  of  Ritter's^  190  cases  being  of  this  nature,  and  in  97  the  hemor- 
rhage being  limited  to  this  region.  It  may  occur  as  a  result  of  accident 
or  as  a  manifestation  of  a  general  hemorrhagic  condition  (see  Umbilical 
Hemorrhage,  p.  292)  and  is  very  often  combined  with  bleeding  from 
other  parts  of  the  body.  Widespread  subcutaneous  hemorrhages  are 
not  uncommon.  They  develop  oftenest  in  parts  most  pressed  upon, 
although  other  regions  are  not  spared.  Bleeding  from  the  skin  following 
a  shght  wound,  as  for  an  examination  of  the  blood,  is  not  infrequent  in 
hemorrhagic  cases. 

Symptoms. — The  traumatic  hemorrhages,  due  as  they  generally 
are  to  injury  at  birth,  as  a  rule  reveal  themselves  promptly,  except  those 
of  the  abdominal  and  thoracic  viscera,  where  no  symptoms  at  all  may 
appear  until,  perhaps,  a  sudden  collapse  occurs  followed  promptl}^  by 
death.  Those  of  a  spontaneous  nature  manifest  themselves  generally 
by  visible  bleeding  in  several  regions  of  the  body.  Inasmuch  as  infants 
tolerate  loss  of  blood  very  badly,  a  comparatively  small  hemorrhage  may 
readily  produce  weakness  of  pulse,  great  depression  of  strength  and  loss 
of  weight.  Anemia  is  a  natural  result.  The  temperature  may  be  ele- 
vated, but  is  often  subnormal.  Icterus  is  a  common  sj^nptom.  It  was 
seen  in  21  per  cent,  of  Hitter's  cases.  As  a  rule  the  amount  of  blood  lost 
at  one  time  is  small.  It  is  the  repealled  losses,  and  especially  losses  in  many 
l)arts  of  the  body,  which  occasion  the  general  symptoms  in  inosi   cases. 

'L'()bst('tri(iuc,  1011,  IV,  S2.-). 

-  Ann.  fj;vncc.  ct  d'obstct.,  1!)()3,  LIX,  253. 

^Sparcda  Vop.,  1902,  11.  3.,  Kef.  Jalirl)    f.  Kiiidorh.,  1903,  L\ll,  105. 

^  Loc.  cit.,  190. 


266  THE  DISEASES  OF  CHILDREN 

Prognosis  and  Course. — These  depend  much  on  the  cause,  on  the 
amount  of  blood  lost,  and  on  the  duration  of  the  process.  The  mortality- 
was  formerly  high;  75.79  per  cent,  in  Ritter's  cases  of  spontaneous  hemor- 
rhage and  62  per  cent,  in  Townsend's  50  cases;  while  in  609  published 
reports  of  hemorrhage  collected  by  the  latter  writer  the  mortality  was 
79  per  cent.  Of  recent  years  improved  methods  of  treatment  have 
decidedly  diminished  the  death-rate.  Death  in  the  fatal  cases  generally 
occurs  within  a  week.  It  may  be  very  sudden  from  collapse  when  the 
hemorrhage  is  large. 

Diagnosis. — Where  the  bleeding  is  evident  to  the  eye  the  diagnosis 
is  easy.  Where  it  is  concealed  it  is  difficult  and  often  impossible.  The 
determining  of  the  nature  of  the  cause  is  important.  As  a  general  rule 
large  single  hemorrhages  are  the  result  of  local  processes,  while  widespread 
multiple  hemorrhages  depend  upon  sepsis,  syphilis,  or  the  general  hemor- 
rhagic condition  referred  to.  Of  course,  the  discovery  of  blood  effused 
in  or  from  only  one  part  of  the  body  does  not  prove  that  concealed 
visceral  bleeding  may  not  be  taking  place  as  well. 

Treatment. — Local  measures  to  arrest  bleeding  are  indicated 
where  applicable.  Among  these  are  the  use  of  astringents,  especially 
the  application  of  a  caustic,  such  as  nitrate  of  silver  in  solid  form, 
liquor  ferri  subsulphatis  or  chromic  acid.  The  exhibition  of  gelatine 
in  10%  solution  administered  internally  freely  has  been  largelj^  employed, 
and  appears  to  be  of  value.  From  10  to  50  c.c.  (0.34  to  ]  .69  fl.oz.)  may  be 
given  subcutaneously  once  or  twice  a  day  with  the  greatest  caution  to 
obtain  complete  sterilization  and  to  follow  aseptic  precautions,  lest  septic 
infection  or  even  tetanus  result.  Internally  gelatine  may  be  adminis- 
tered either  by  the  mouth  or  by  the  rectum.  Adrenahn  chloride  has  been 
recommended,  giving  1  to  4  minims  (0.062  to  0.246)  of  a  1:1000  solution 
internally.  Calcium  chloride  or  lactate  in  amounts  of  20  to  40  grains 
(1.3  to  2.6)  in  24  hours  in  divided  doses  may  also  be  employed.  One  of 
the  best  of  remedies  is  the  administration  of  a  blood-serum.  Human 
blood  from  a  parent  may  be  given  by  direct  transfusion,  or  this  or  the 
serum  be  injected  subcutaneously,  as  recommended  by  J.  E.  Welch^  in 
quantities  of  from  10  to  30  c.c.  (0.34  to  1 .01  fl.oz.)  every  4  to  8  hours.  To 
prevent  clotting  the  blood  before  injection  may  be  mixed  with  a  2  per  cent, 
sterilized  sodium-citrate  solution  in  the  proportions  of  1  :  10.  (See  p. 
246.)  Should  human  blood  not  be  available,  horse-serum  or  rabbit- 
serum  may  be  given  subcutaneously  in  the  same  amount,  diphtheria- 
antitoxin  being  selected  for  this  purpose  if  nothing  else  can  be  obtained. 
In  the  way  of  general  treatment  the  loss  of  blood  must  be  made  up  by 
subcutaneous  or  rectal  injections  of  normal  salt-solution,  the  tem- 
perature maintained,  and  the  strength  supported. 


MELENA  NEONATORUM 

In  this  form  of  hemorrhage  in  the  new  born  are  grouped  cases  which 
are  quite  dissimilar  in  origin  and  natui'e,  but  which  show  the  characteris- 
tic symptom,  i.e.,  the  discharge  of  black  altered  blood  {/jLeXatva:  black) 
from  the  intestines  or,  by  vomiting,  from  the  stomach.  The  condition 
was  first  described  by  Ebart  in  1723. ^  The  title  should  be  reserved  to 
describe  the  symptom  merely;  not  the  cause. 

1  Amer.  Jour.  Med.  Sci.,  1910,  CXXXIX,  800. 

2  Wiederhhofer,  Gerhardt's  Handb.  d.  Kinderkr.,  IV,  2,  408. 


HELENA  NEONATORUM  267 

Etiology. — The  affection  is  sometimes  divided  into  Helena  spuria 
and  Helena  vera.  In  the  former  the  blood  enters  the  infant's  stomach 
or  intestines  from  outside  sources,  as  from  a  hemorrhage  from  the  mouth, 
nose  or  lungs,  a  wound  in  the  nipple  of  the  nurse,  or  from  the  swallowing 
of  maternal  blood  during  labor.  In  melena  vera,  which  is  the  form 
about  to  be  considered,  it  comes  from  the  effusion  of  blood  into  the  stom- 
ach or  intestines.  Even  the  cases  of  the  latter  group  may  be  divided 
into  the  sympto7natic,  in  which  other  manifestations,  often  hemorrhagic, 
of  a  constitutional  disease  are  present,  and  the  idiopathic,  in  which  the 
melena    is    the  only    sjTnptom  of  a  hemorrhagic  condition  observed. 

Melena  is  a  comparatively  uncommon  disorder  occurring  about  once 
in  every  1000  or  2000  births,  according  to  different  estimations  (Gerhardt- 
Seiffert).^  The  etiology  is  not  clearly  understood,  and  certainly  varies 
with  the  case.  Lesions  of  the  mucous  membrane  or  of  the  deeper  vessels 
of  the  gastroenteric  canal  are  prominent  causes,  but  the  method  of  pro- 
duction of  these  lesions  is  far  from  clear.  Often  they  are  the  result  of 
congestion,  which  may  itself  be  brought  about  in  various  ways  incident  to 
birth,  such  as  prolonged  asphyxia,  violent  efforts  at  extracting  the  child 
or  at  its  resuscitation,  compression  of  the  umbilical  cord,  congenital  dis- 
eases of  the  heart,  congenital  syphilitic  hepatitis,  and  the  like.  In  other 
instances  some  constitutional  condition  has  produced  a  weakness  of  the 
vessels  or  an  alteration  of  the  blood  itself;  among  these  causes  being 
syphilis  and  sepsis,  the  melena  being  then  only  one  of  the  evidences  of 
the  hemorrhagic  tendency  present.  A  delay  in  the  coagulation  of  the 
blood  is  said  by  Lovegren^  to  be  present.  Various  bacteria  have  been 
reported  as  found  from  time  to  time  but  their  relationship  to  melena 
has  never  been  satisfactorily  proven.  It  is  probably  very  close  in  some 
instances,  but  of  no  bearing  in  others.  The  influence  of  the  development 
of  ulcers  in  the  gastroenteric  tract,  especially  the  duodenum,  in  giving 
rise  to  gastrointestinal  hemorrhage  is  easy  to  appreciate,  but  the  method 
of  production  of  such  ulcers  is  not  well  understood ;  whether  embolic,  or 
dependent  on  erosion  after  hemorrhage  into  the  mucous  membrane.  (See 
Ulcer  of  the  Duodenum,  p.  797.)  Ulceration  is,  however,  not  a  com- 
mon post-mortem  finding  in  fatal  cases  of  melena.  In  many  instances  it 
would  appear  as  though  the  blood  makes  its  way  from  the  vessels  through 
the  mucous  membrane  of  the  intestine  without  any  discoverable  lesion. 

Pathological  Anatomy. — The  surface  of  the  body  and  the  internal 
organs  are  anemic,  and  the  gastrointestinal  canal  is  found  filled  with 
blackish  fluid.  Beyond  these  there  is  no  uniformity  in  the  conditions 
present.  Occasionally  ulcers  are  discovered  on  the  mucous  membrane 
of  the  stomach  or  intestine,  especially  the  duodenum.  They  may  be 
very  minute  or  larger,  and  sometimes  exhibit  the  characteristic  appear- 
ance of  the  ordinary  peptic  ulcer.  In  some  cases  only  minute  erosions 
and  in  others  only  minute  extravasations  of  blood  are  found.  VorpahP 
reported  an  instance  of  melena  dependent  upon  rupture  of  dilated  veins 
in  the  esophagus.  In  the  large  majority  of  cases  nothing  whatever  of 
moment  is  discovered  in  the  gastrointestinal  tract  at  autopsy.  Careful 
study  of  other  parts  of  the  body  may  reveal  the  evidences  of  sepsis 
or  of  syphilis,  or  the  characteristic  lesions  of  acute  fatty  degeneration. 

Symptoms. — Although  in  a  certain  proportion  of  cases  there  is 
some  asphyxia  at  birth,  in  the  large  majority  the  child  is  of  healthy 

iLehrb.  d.  Kinderkr.,  1897,  71. 

2  Jahrb.  f.  Kinderh.,  1914,  LXXIX,  708. 

3  Arch.  f.  Gyniik.,  1912,  XCVI  ,  377. 


268  THE  DISEASES  OF  CHILDREN 

appearance.  The  discharge  of  blood  begins  usually  on  the  2d  day  of 
life  and  seldom  later  than  the  4th  day.  In  most  cases  the  blackish  or 
blackish-red  matter  is  both  vomited  and  evacuated  by  the  bowel,  but 
in  many  instances  it  is  passed  from  the  bowel  only.  In  an  analysis  by 
Vassmer^  of  67  published  cases  blood  was  found  in  the  stools  alone  in  20, 
in  the  vomitus  alone  in  6,  and  in  both  in  37.  The  amount  lost  may  be 
slight,  but  it  is  oftener  so  large  that  the  infant  rapidly  becomes  very 
anemic,  apathetic,  prostrated,  with  feeble  cry,  and  finally  collapsed. 
There  may  be  slight  transitory  fever,  or  normal  or  subnormal  tempera- 
ture. As  a  rule  there  is  no  distention  or  tenderness  of  the  abdomen. 
The  disease  seldom  lasts  longer  than  2  to  3  days.  In  the  cases  which 
survive  recovery  is  rapid,  except  from  the  anemia,  unless  some  consti- 
tutional disorder,  such  as  syphilis,  is  accountable  for  the  hemorrhage 
and  keeps  the  child  ill  in  other  ways.  The  disappearance  of  the  anemia, 
of  course,  requires  a  longer  time. 

Prognosis. — The  death-rate  is  high,  probably  between  50  per  cent,  and 
60  per  cent.  (56  per  cent.Silbermann).^  In  the  cases  of  idiopathic  melaena 
vera;  i.e.  those  in  which  the  hemorrhage  is  limited  to  the  gastrointestinal 
tract  and  is  not  a  symptom  of  a  general  hemorrhagic  diathesis,  the  mor- 
tality is  distinctly  less  than  the  figures  given.  The  mortality  is  less  also . 
in  the  cases  where  the  hemorrhage  is  from  the  bowel  only  than  when  there 
is  hematemesis.  Thus  in  the  20  cases  of  Vassmer's  series  in  which  the 
hemorrhage  was  from  the  bowel  alone  the  mortality  was  10  per  cent.  The 
liability  of  death  depends  largely  on  the  cause  of  the  bleeding  and  on 
the  amount  of  it. 

Diagnosis.^ — ^Melaena  vera  is  to  be  sharply  distinguished  from  the 
spurious  melena  referred  to.  In  the  latter  the  hemorrhage  is  seldom  large; 
it  does  not  always  begin  so  early  in  life ;  and  the  child  does  not,  as  a  rule, 
appear  ill.  Examination  of  the  nipple  of  the  mother  and  of  the  nose  and 
mouth  of  the  child  may  discover  the  source.  When  melena  is  limited  to 
discharge  of  blood  from  the  intestines  it  may  be  readily  confounded  with 
the  passage  of  meconium,  especially  in  mild  cases,  and  be  easily  over- 
looked. The  material  is,  however,  evacuated  more  frequently  incases 
of  melena,  and  the  slightly  reddish  color  of  the  blackish  masses  or  of  the 
diaper  serves  to  distinguish  it.  The  use  of  the  microscope,  especially 
the  combined  chemical  and  microscopical  examination  for  blood  corpus- 
cles and  hemin  crystals,  makes  the  diagnosis  positive.  Finally,  the 
presence  of  hemorrhages  from  other  parts  of  the  bodj^  or  of  symptoms 
other  than  those  described  will  remove  the  case  at  least  from  the  cate- 
gory of  idiopathic  melaena  vera.  Occasionally  the  gastrointestinal 
hemorrhage  is  concealed,  and  the  child  dies  without  any  external  bleed- 
ing having  taken  place.  In  such  instances  an  antemortem  diagnosis 
is  not  possible. 

Treatment. — This  consists  in  supporting  the  strength  and  checking 
the  hemorrhage.  Stimulants,  digitalis,  the  maintaining  the  temperature, 
and  the  administration  of  food  are  required.  Cold  to  the  abdomen  may 
check  the  hemorrhage,  but  is  generally  poorly  tolerated  by  infants. 
Tincture  of  the  chloride  of  iron  (1  minim)  (0.062)  or  fluidextract  of  ergot 
(2  to  5  minims)  (0.123  to  0.308)  has  been  recommended.  Calcium  lactate, 
20  to  40  grains  (1.3  to  2.6)  in  24  hours,  appears  serviceable.  Gelatine 
seems  to  be  the  best  of  remedies.  It  may  be  given  by  the  mouth  in 
a  5  to  10  per  cent,  solution,  as  for  any  form  of  hemorrhage  in  the  new 

1  Arch.  f.  Gynak.,  1909,  LXXXIX,  275. 

2  Jahrb.  f.  Ivinderh.,  1877,  XI,  378. 


CEPHALHEMATOMA  269 

born.  (See  p.  266.)  The  subcutaneous  injection  of  human  blood  or 
serum,  or  of  horse  or  rabbit  serum,  has  Hkewise  been  proven  valuable  (p. 
266)  in  the  hands  of  many  physicians. 

CEPHALHEMATOMA 

By  this  title  is  designated  a  form  of  hemorrhage  in  the  new  born  pro- 
ducing a  fluctuating  swelling  situated  between  the  bones  of  the  skull  and 
the  overlying  tissues  (cephalhematoma  externum).  Sometimes  the 
blood  is  effused  within  the  skull  between  the  bone  and  the  dura  mater 
(cephalhematoma  internum).  The  description  which  follows  applies 
almost  entirel}^  to  the  external  variet3^ 

Etiology. — The  disease  is  not  very  common.  Hennig^  found  it 
recorded  230  times  in  53,506  newborn  infants,  i.e.  0.43  per  cent.,  and  Hof- 
mokl-  371  times  in  59,885  cases;  i.e.  0.6  per  cent.  Almost  always  the 
condition  develops  in  the  first  few  days  of  life,  but  very  rarely  cases  have 
been  recorded  occurring  in  the  first  weeks  or  months,  or  even  later  in 
infancy.  (Friedmann^ — case  in  a  child  of  4  years.)  Males  are  much 
oftenest  affected. 

The  direct  cause  of  cephalhematoma  is  often  some  injury  received 
during  birth.  Thus  it  occurs  much  most  frequently  in  the  children  of 
primiparse  (34  out  of  40  cases,  Meyer*),  and  in  vertex  presentations  when 
pressure  has  been  long  continued.  The  circular  pressure  exercised  by  the 
uterus  and  the  absence  of  this  over  the  central  presenting  part,  probably 
tends  to  make  the  vessels  yield  and  break.  Yet  in  very  many  instances  no 
evidence  of  direct  trauma  can  be  discovered,  and  the  lesion  appears  to 
be  due  entirely  to  other  causes.  The  condition  may  even  develop  in 
premature  infants  or  after  very  easy  labor,  or  sometimes  in  breech  pre- 
sentations. The  presence  of  asphyxia  tends  decidedly  to  produce  it, 
and  it  may  also  be  one  of  the  evidences  of  a  general  hemorrhagic  disorder 
in  the  new  born.  The  looseness  with  which  the  periosteum  is  attached 
to  the  underlying  bone  in  the  new  born,  and  the  delicacy  of  the  blood- 
vessel walls,  also  predispose  to  its  development. 

Pathological  Anatomy.^ — The  lesion  is  generally  unilateral,  yet 
it  may  be  bilateral,  and  rarely  even  appears  over  3  different  bones.  The 
seat  of  the  swelling  is  much  more  frequently  over  the  right  parietal  bone. 
Hennig^  reported  it  here  in  57,  and  over  the  left  parietal  bone  in  37, 
out  of  127  cases.  The  hemorrhage  takes  place  below  the  periosteum, 
lifting  this  from  the  bone  possibly  as  far  as  the  sutures,  where  it  adheres 
too  firmly  to  permit  of  it.  The  blood  remains  fluid  sometimes  even  for 
some  weeks.  It  averages  from  0.5  to  1.5  fl.oz.  (15  to  44)  in  amount,  but 
it  may  be  much  more  than  this.  In  recent  cases  it  is  discharged  with  a 
spurt  when  incision  is  made.  The  bone  is  pale,  rough,  and  often  covered 
with  fibrinous  clots.  An  exudate  of  new  osseous  tissue  forms  a  periph- 
eral boundary-ridge  upon  the  bone  about  the  tumor.  This  is  soft 
and  velvety  in  recent  cases,  but  later  hard  and  projecting  distinctly  above 
the  surface  of  the  skull. 

The  periosteum  over  the  swelling  is  bluish  and  often  covered  with 
small  effusions  of  blood.     In  advanced  cases  small  plates  of  new  bono 

'  Gerhanlt's  Handb.  d.  Kindorkr.,  II,  49. 

2  Arch.  f.  Kindcrh.,  1S80,  I,  309. 

3  Miinch.  ined.  Woc-henschr.,  1904,  LI,  387. 

*  HospitaLstidende,  1897,  IV,  585. 

*  Loc.  cit. 


270 


THE  DISEASES  OF  CHILDREN 


are  deposited  here  and  there  in  the  periosteum.     Section  of  the  scalp 
over  the  swelhng  shows  numerous  scattered  punctiform  hemorrhages. 

Quite  exceptionally  the  bleeding  instead  of  taking  place  under  the 
periosteum  occurs  under  the  aponeurosis  (cephalhematoma  snbaponeuro- 
tica).  In  such  cases,  of  course,  no  bony  ridge  exists  and  the  tumor  is  not 
necessarily  limited  bj''  the  sutures.  Both  varieties  may  occur  together. 
Infrequently  examination  within  the  skull  reveals  also  a  hemorrhage 
between  the  dura  mater  and  the  bone,  corresponding  in  position  to  the 
hematoma  outside  and  perhaps  connecting  with  it.  McKee^  found  this 
internal  cephalhematoma  reported  in  but  16  instances  in  medical  litera- 
ture, in  11  of  these  associated  with  the  external  variety.  When  there 
has  been  decided  trauma  during  labor  fissures  or  fractures  of  the  bones  of 
the  skull  may  be  present.  In  the  cases  depending  upon  constitutional 
conditions  hemorrhages  occur  in  other  parts  of  the  body  as  well. 

Symptoms  and  Course. — Although  generally  discovered  2  to  3 
days  after  birth  the  condition  begins  earlier  than  this  but  is  not  noticed. 

Sometimes  it  is  at  first  con- 
cealed by  a  caput  succedaneum, 
and  only  becomes  visible  as 
this  disappears.  It  is  at  first 
small,  but  grows  rapidly.  Its 
maximum  size  is  attained  in 
from  6  to  8  days,  the  bleeding 
then  ceasing,  and  the  tumor 
varying  in  size  up  to  that  of  a 
large  hen's  egg  (Fig.  46).  It 
is  at  first  rather  flat  and  soft, 
but  soon  becomes  rounded  and 
tense  although  fluctuating.  It 
is  not  hot  or  tender  to  the  touch 
and  rarely  pulsates.  It  cannot 
be  reduced  by  pressure,  and  is 
not  affected  by  crying.  The 
skin  over  it  is  sometimes  darker 
in  color  than  normal  but  otherwise  unaltered  in  appearance.  The 
change  in  color  is  observed  especially  when  the  hemorrhage  is  subaponeu- 
rotic. The  tumor  covers  all  or  a  part  of  one  of  the  bones  of 'the 
skull,  but  if  subperiosteal  never  passes  beyond  the  sutures  or  over  the 
fontanelle.  Where  the  swelling  appears  to  cover  th^  adjoining  bone  also 
it  is  really  a  double  cephalhematoma,  and  a  distinct  groove  can  be  felt 
beneath  the  two  at  the  position  of  the  suture. 

After  the  tumor  has  existed  from  2  to  3  days,  a  soft  ridge  can  be  felt 
forming  around  its  periphery.  This  later  becomes  harder  and  thicker  as 
osseous  tissue  develops  in  it,  and  gives  very  much  the  sensation  of  a  soft 
mass  protruding  through  a  large  hole  in  the  skull.  The  tumor  maintains 
its  size  unabated  until  its  2d  week  and  then  begins  slowly  to  grow 
smaller  and  less  tense.  As  this  occurs  the  bony  periphery  broadens 
toward  the  centre.  A  parchment-like  sense  of  crepitation  can  now 
often  be  developed  on  palpation,  dependent  upon  the  new  osseous  growth 
in  the  periosteum. 

Although  recovery  is  exceptionally  more  rapid,  as  a  rule  absorption  of 
the  effused  blood  goes  on  very  slowly  and  the  tumor  does  not  disappear 
for  2  or  3  months  from  the  onset.     The  bony  ridge  may  be  still  felt  more 
1  Cincin.  Lancet-Clinic,  1883,  XI,  317. 


Fig. 


46. — Cephalhematoma. 
(From  a  photograph.) 


CEPHALHEMATOMA  271 

or  less  distinctly  for  months  more,  or  the  whole  region  of  the  tumor  may- 
be left  somewhat  thickened.     General  symptoms  are  entirely  absent. 

Occasionally  the  course  is  not  so  favorable.  Suppuration  may  take 
place  within 'the  tumor,  especially  if  there  are  external  wounds  of  the 
scalp  present.  In  this  event  the  swelling  becomes  red  and  tender,  and  the 
infant  is  evidently  ill  with  the  general  symptoms  of  suppm-ation.  The 
abscess  which  forms  may  discharge  externally  and  be  followed  by  healing, 
or  it  may  give  rise  to  a  diffuse  inflammation  of  the  tissues  of  the  scalp 
with  involvement  of  the  bone  and  secondary  meningitis.  In  other  cases 
the  prolonged  suppuration  produces  fatal  exhaustion  or  general  sepsis. 

Sometimes  the  disease  is  complicated  by  cerebral  symptoms  from  the 
beginning.  In  such  instances  it  is  probable  that  there  is  an  internal 
cephalhematoma  or  a  meningeal  hemorrhage  also  present. 

Prognosis. — This  is  entirely  favorable  in  every  uncomphcated  case, 
and  where  the  hematoma  is  not  the  result  of  a  general  disorder.  The 
development  of  suppuration  in  the  tumor  is  a  serious  complication,  but 
a  rare  one,  and  makes  the  prognosis  doubtful.  Still  more  serious  is  the 
presence  of  a  complicating  hematoma  within  the  cranium.  These 
cases  are  fortunately  exceptional,  since  they  nearly  always  die. 

Diagnosis.- — -Between  the  subperiosteal  and  the  subaponeurotic 
cephalhematomata  the  distinction  may  be  made  by  the  presence  in  the 
former  of  a  distinct,  hard,  marginal  ring,  the  limitation  by  the  sutures, 
and  the  absence  of  decided  discoloration  of  the  skin.  Hematoma  may 
be  readily  confounded  with  caput  succedaneum  during  the  first  few  days 
of  life.  This  condition  consists  of  an  edematous  swelling  of  the  connect- 
ive tissue  of  that  portion  of  the  scalp  which  has  been  presenting 
through  the  patulous  os  uteri,  and  is  the  result  of  the  obstruction  to  the 
circulation  at  the  periphery  and  the  absence  of  pressure  over  the  swollen 
region.  The  fact  that  it  disappears  in  a  few  days,  and  the  absence 
of  fluctuation  and  of  the  development  of  any  marginal  wall  also  serve 
to  distinguish  it  from  cephalhematoma.  Meningocele  and  encephalocele 
resemble  cephalhematoma  to  some  extent.  They  may  exhibit  pulsa- 
tion, are  influenced  by  respiration  and  by  crying,  are  to  some  extent  re- 
ducible often  with  the  production  of  convulsions,  and  correspond  in 
position  with  a  suture  or  a  fontanelle.     (See  Meningocele,  Vol.  II,  p.  311.) 

Abscess  of  the  scalp  is  attended  by  heat,  tenderness,  and  discoloration 
of  the  skin,  with  constitutional  symptoms.  A  telangioma  resembles  a 
hematoma  but  slightly.  There  is  no  bony  wall  or  fluctuation,  while 
crying  makes  it  larger  and  pressure  somewhat  smaller  and  the  skin  is 
discolored. 

Treatment. — The  best  treatment,  as  a  rule,  appears  to  be  a  wholly 
expectant  one.  The  child  should  be  so  placed  that  no  injury  to  the  hema- 
toma can  occur,  and  recovery  entrusted  to  time.  No  applications  are 
required.  Many  writers  have  urged  early  incision  in  order  to  drain  away 
the  fluid  blood  and  hasten  recovery.  This,  however,  adds  an  unnecessary 
element  of  danger,  in  that  there  is  the  possibility  of  producing  sepsis 
through  the  open  wound,  beside  the  chance  of  having  a  secondary  hemor- 
rhage occur.  The  expectant  treatment  although  slow  is  safe.  On  the 
slightest  evidence  of  suppuration  beginning  the  hematoma  should  be 
incised  and  drained  antiseptically.  If  there  are  indications  of  intra- 
cranial pressure,  and  an  internal  cephalhematoma  comnuinicating  with 
an  external  one  is  suspected,  the  question  of  aspiration  by  puncture  with 
antiseptic  precautions  is  to  be  considered. 


272  THE  DISEASES  OF  CHILDREN 

HEMATOMA  OF  THE  STERNOCLEIDOMASTOID  MUSCLE 

This  consists  of  a  hemorrhage  into  the  body  of  the  sternocleido- 
mastoid muscle.  It  is  of  rare  occurrence  and  is  the  result  of  injury 
received  during  birth.  In  about  75  per  cent,  of  the  cases  this  is  pro- 
duced by  traction  upon  the  legs  in  breach  presentations,  as  a  result  of 
which  the  blood-vessels  in  the  neck  are  torn  and  a  blood-tumor  results. 
It  ma}'  be  brought  about  also  by  the  pressure  of  forceps  in  vertex 
presentations  or  maj^  occur  without  any  cause  for  the  lesion  being 
discoverable. 

The  tumor  produced  is  quite  small,  not  over  ll^  inches  (3.8  cm.)  in 
length.  It  is  tender  on  pressure  due  to  the  attending  myositis,  and 
at  first  soft.  The  skin  over  it  is  not  discolored.  Soon  it  becomes  hard 
and  the  tenderness  disappears  as  cicatricial  changes  take  place  in  it. 
It  may  occupy  any  position  of  the  muscle  but  is  oftenest  in  the  middle  or 
upper  part,  and  is  most  frequently  situated  upon  the  right  side,  only 
exceptionally  occurring  upon  both  sides.  In  38  cases  reported  by 
Henoch^  the  right  side  was  involved  in  31.  Although  produced  at  birth 
it  generally  does  not  become  apparent  until  the  age  of  2  weeks  or  later, 
especially  if  the  neck  is  fat.  The  rigid  inclination  of  the  head  of  the 
infant  toward  the  affected  side  with  the  chin  turned  toward  the  other' 
is  a  symptom  often  present  which  leads  to  the  examination  of  the  neck 
and  the  discovery  of  the  swelling. 

The  immediate  prognosis  is  nearly  always  good.  The  swelling  slowly 
grows  smaller,  although  it  may  not  entirely  disappear  for  a  few  months. 
It  is  probable,  however,  that  the  rigidity  of  the  neck  may  in  rare  instances 
remain  throughout  life.  The  cases  of  so-called  congenital  torticollis 
are  probably  produced  in  this  way.     (See  TorticolKs,  Vol.  II,  p.  41].) 

No  treatment  except  rest  is  required  in  the  acute  stage.  Later  gentle 
massage  and  passive  movements  of  the  head  may  be  of  benefit.  Should 
persistent  torticollis  remain  surgical  treatment  may  be  demanded  later, 
in  the  form  of  orthopedic  apparatus  or  of  operative  interference. 


CHAPTER  VI 
ICTERUS  IN  THE  NEW  BORN 

Icterus  is  of  very  frequent  occurrence  in  the  new  born,  and  may  depend 
upon  various  causes.  It  may  conveniently  be  divided  into  (1)  sympto- 
matic, and  (2)  idiopathic  icterus. 

1.  Symptomatic  icterus  depends  upon  such  general  diseases  as  infec- 
tious hemoglobinemia,  acute  fatty  degeneration  of  the  new  born,  sepsis, 
syphilitic  hepatitis,  congenital  cirrhosis  of  the  liver  and  congenital 
obliteration  of  the  bile-ducts.  These  are  all  of  rare  occurrence.  The 
ordinary  gastroduodenal  catarrh  with  closure  of  the  common  bile-duct, 
which  occasions  icterus  so  frequently  in  adult  life,  is  often  a  cause  in  the 
new  born  also  and  is  liable  to  be  more  severe  than  in  later  life.  Most 
of  the  forms  of  symptomatic  icterus  are  discussed  elsewhere  in  course, 
with  the  exception  of  that  depending  upon  the  congenital  obliteration 
of  the  ducts  to  which  brief  special  consideration  may  be  given. 

1  Vorlesungen  iiber  Kinderkrankheiten,  1895,  35. 


CONGENITAL  OBLITERATION  OF  THE  BILE-DUCTS  273 

In  symptomatic  icterus  the  discoloration  of  the  skin  is  generally 
very  decided,  and  there  are  other  symptoms  of  the  causative  disease 
evident.  The  urine  often  shows  the  presence  of  bile,  and,  in  obstructive 
jaundice,  the  feces  often  the  absence  of  it. 

2.  In  idiopathic  icterus  in  the  new  born  there  is  present  no  discoverable 
congenital  or  acquired  anatomical  defect  which  can  produce  jaundice  by 
obstruction,  and  no  constitutional  disease  to  account  for  it.  It  appears  to 
be  almost  of  a  physiological  nature,  and  there  are  no  other  symptoms 
attending  it.  To  this  form  the  title  "Icterus  Neonatorum"  is  commonly 
applied. 

CONGENITAL    OBLITERATION    OF    THE    BILE-DUCTS 
(Congenital  Biliary  Cirrhosis) 

This  is  a  rare  condition  of  which,  however,  according  to  Thomson^ 
more  than  100  cases  had  been  reported  at  the  date  of  his  writing. 
Holmes^  in  a  very  careful  review  of  the  subject  published  in  1916  esti- 
mates that  nearly  120  cases  have  been  reported.  I  have  observed  2 
instances  of  it,  verified  by  autopsy.^  Congenital  biliar}'-  cirrhosis, 
although  described  as  a  distinct  affection,  would  seem  probably,  as 
claimed  by  Skormin,*  and  by  Rolleston  and  Hayne^  to  be  of  the  same 
nature  as  obliteration  of  the  bile-ducts,  both  in  pathogenesis  and  in 
symptomatology. 

Etiology  and  Pathology. — The  cause  is  Uttle  understood.  The 
disease  is  lial)le  to  occur  in  several  members  of  one  family,  this  supporting 
the  view  that  there  exists  some  congenital  failure  in  deVelopment.  Some 
cases  indicate  the  existence  of  a  prenatal  obliterative  inflammation  of 
the  bile-ducts,  which  either  starts  as  a  biliary  cirrhosis  and  descends 
to  the  larger  ducts,  or  in  which  the  two  regions  are  affected  at  the  same 
time.  Still  another  view  makes  the  cirrhosis  secondary  to  complete 
obliteration  of  the  main  ducts  and  dependent  upon  the  interference 
with  the  exit  of  bile.  One  of  my  cases  supports  this  view.  Thomson 
has  shown  that  a  biliary  cirrhosis  was  present  in  nearly  all  of  the  reported 
cases  which  he  collected. 

It  does  not  seem  likely  that  syphilis  plays  any  important  part  in  the 
etiology.  Some  of  the  instances  of  severe  congenital  icterus  may  pos- 
sibly be  due  to  a  partial  obliteration  of  the  bile-ducts  involving  the 
mucous  meml)rane  of  the  ducts  and  to  a  certain  extent  the  connective 
tissue  as  well,  but  never  advancing  to  complete  obstruction.  This 
theory  would  explain  certain  cases  of  jaundice  reported  by  Arkwright,® 
Weber^  and  Pearson.^  It  is  certain  that  the  obstruction  may  occasionally 
not  be  complete  at  first,  and  that  entire  obliteration  may  develop  only 
considerably  later. 

Pathological  Anatomy. — The  l)ile-ducts  may  be  undiscoverable  or 
they  may  be  replaced  l)y  a  fibrous  cord;  or  there  may  be  ol)literation  at 
but  a  single  point,  the  ducts  above  this  being  without  stenosis.     The 

1  AUbutt  and  iioUeston,  System  of  Med.,  1908,  IV,  1,  103. 

2  Amer.  Jour.  Dis.  Child.,  191G,  XI,  405. 

3  Arch,  of  Ped.,  1905,  XXII,  257.      Ibid.,  1908,  XX\',  March. 
Mahrb.  f.  Kinderh.,  1902,  L\'I,  203. 

'  Brit.  Med.  .louni.,  1901,  I,  758. 
»  KdinbiirKli  Mi'd.  .lourii.,  1902,  LIV,  15(). 
'  Edinl)iirKh  Med.  Journ.,  1903,  LVI,  111. 
«  Underwood's  Dis.  of  Child,  1846,  10th  Edit.,  108. 
18 


274  THE  DISEASES  OF  CHILDREN 

gall-bladder  may  be  absent  or  distended.  The  liver  is  generally  en- 
larged, firm,  and  of  normal  or  greenish  color,  and  in  most  cases  exhibits 
the  histological  lesions  of  hypertrophic  cirrhosis.  The  blood-vessels  are 
seldom  involved;  the  spleen  is  enlarged. 

Symptoms. — The  principal  symptom  is  icterus,  which  is  present 
at  birth  or  develops  within  the  1st  week  or  occasionally  later.  The 
color  is  intense  and  often  of  a  greenish  hue.  The  occurrence  of  acholic 
stools  is  also  of  importance.  Sometimes  ordinary  yellow  movements 
are  present  at  first,  to  be  replaced  later  by  the  characteristic  appearance. 
The  passage  of  green  feces  does  not,  of  course,  necessarily  indicate  the 
presence  of  bile.  The  urine  is  intensely  bile-stained;  fever  is  not  a 
S3^mptom;  but  vomiting  is  liable  to  occur.  Hemorrhages  from  the 
umbilical  cord  and  into  different  parts  of  the  body  are  a  very  char- 
acteristic symptom,  yet  in  no  way  pathognomonic,  as  they  may  appear 
in  severe  icterus  from  other  causes.  Emaciation  develops  if  the  case 
is  at  all  prolonged. 

Course  and  Prognosis. — The  outcome  is  necessarily  fatal,  if  we 
include  among  the  cases  only  those  in  which  complete  organic  obliteration 
finally  occurs.  The  course  is  seldom  acute.  Death  takes  place  in  con- 
vulsions or  stupor,  generally  only  after  several  weeks  or  even  months, 
although  sometimes  the  child  dies  in  the  1st  week  of  the  disease. 

Treatment  can  be  only  palliative  and  symptomatic.  Operative 
interference  at  this  early  age  appears  to  offer  little  hope;  both  on  account 
of  the  difficulties  attending  it,  and  because  biliary  cirrhosis  is  usually 
combined  with  the  obliteration. 

ICTERUS  NEONATORUM 

Etiology  and  Pathogenesis. — The  condition  is  a  very  common 
one,  ranging  according  to  different  statistics  from  15.69  per  cent.  (Seux)^ 
to  84.46  per  cent.  (Cruse)  ^  of  all  births.  It  is  probable  that  careful  ob- 
servation would  show  it  present  to  at  least  a  slight  degree  in  the  great 
majority  of  the  new  born.  Boys  are  oftener  affected  than  girls;  the  first- 
born children  oftener  than  later  ones,  and  premature,  light-weight,  or 
atelectatic  infants  oftener  than  others  (Kehrer).^ 

Regarding  the  exciting  causes  of  the  condition  and  the  method  of  its 
production  the  years  of  investigation  have  not  yet^iven  an  entirely  satis- 
factory solution.  The  different  theories  group  themselves  for  the  most 
part  into  two  classes:  first,  that  the  icterus  is  hepatogeneous  in  origin; 
i.e.  arising  from  some  disturbance  in  the  secretion  of  bile  in,  or  its  exit 
from,  the  liver;  second,  that  it  is  hematogeneous;  i.e.  depending  upon 
degeneration  of  the  blood-corpuscles  in  the  circulation  and  the  produc- 
tion in  this  way  of  biliary  coloring  matter.  Although  the  jaundice  may 
perhaps  be  in  part  of  hematogeneous  origin,  it  is  certainly  not  entirely  or 
even  chiefly  so,  since  in  icterus  neonatorum  biliary  acids  are  found  in  the 
serous  fluids  of  the  body  (Runge)'*  and  it  is  admitted  that  these  must  have 
their  origin  in  the  liver.  The  method,  however,  in  which  the  hepato- 
geneous icterus  is  produced  in  the  new  born  is  uncertain  and  various 
theories  exist.  Silbermann^  maintains  that  there  is  an  abundant  break- 
ing up  of  red  blood-cells  in  the  circulation  after  birth.     This  produces  an 

^  Recherches  sur  les  maL  des  enfants  nouveau-nes,  1855,  269. 

2  Arch.  f.  Kinderh.,  1880,  I,  35.3. 

3  Oestcrreich.  Jahrb.  f.  Padiat.,  1871,  II,  71. 
■*  Krankh.  der  ersten  Lebenst.,  1893,  225. 

6  Jahrb.  f.  Kjnderh.,  1887,  XXVI,  252. 


ICTERUS  NEONATORUM  275 

increase  of  material  from  which  bile  is  constructed,  and,  in  addition,  an 
increase  of  fibrin  ferment,  which,  on  its  part,  occasions  great  congestion 
in  the  blood-vessels  of  the  liver,  and  a  consequent  compression  of  the 
biliary  capillaries.  Yllpo^  and  Hirsch^  have  shown  that  the  blood-serum 
of  the  fetus  in  its  last  month  contains  much  more  biliary  pigment  than  is 
present  in  that  of  adults,  and  that  the  amount  increases  still  more  in  the 
first  days  after  birth.  The  liver  is  functionally  immature,  and  is  there- 
fore unable  to  dispose  of  the  excess  of  pigment,  if  this  is  unusually  great, 
which  consequently  enters  the  blood-current  instead  of  the  biliary  capil- 
laries, and  produces  jaundice.  When  the  amount  of  pigment  exceeds  125 
milligrams  per  100  c.c.  of  blood  the  infant  becomes  icteric  (Yllpo).  The 
functional  inability  of  the  liver  to  dispose  of  the  very  large  secretion  of 
bile  in  the  new  born  is  confirmed  by  the  studies  of  Hess.^ 

Among  other  opinions  of  the  etiology,  Birch-Hirschfeld^  believes  that 
icterus  is  due  to  a  compression  of  the  larger  biliary  ducts  by  an  edema 
of  Glisson's  capsule,  the  edema  being  dependent  upon  venous  conges- 
tion incident  to  the  circulatory  changes  following  birth.  Frerichs^and 
others,  on  the  other  hand,  consider  the  icterus  caused  by  a  diminution 
of  venous  blood  present  in  the  liver,  the  result  of  the  cutting  off  of  the 
blood-supply  which  had  been  received  through  the  umbilical  vein.  A 
resorption  of  bile  follows  this.  Still  another  view  which  has  many  adher- 
ents is  that  of  Quincke^  that  the  icterus  depends  upon  an  increased 
production  of  bile  derived  from  the  meconium,  the  resorption  of  this 
from  the  intestine,  and  the  direct  passage  of  it  through  the  patulous 
ductus  venosus  into  the  general  circulation. 

No  theory  advanced  has  not  met  with  opponents,  and  the  question 
still  remains  an  open  one  to  a  large  extent. 

Pathological  Anatomy. — Inasmuch  as  the  condition  is  not  a  fatal 
one,  autopsies  can  be  made  only  on  those  infants  who  have  died  from 
other  causes.  The  skin,  subcutaneous  connective  tissue,  lining  of  the 
arteries,  and  most  of  the  serous  membranes  and  exudates  are  yellow;  the 
extent  of  this  varying  with  the  case.  The  brain,  spinal  cord,  spleen, 
kidneys  and  liver  are  only  slightly  discolored  if  at  all.  The  ductus  chole- 
dochus  is  patulous;  the  kidneys  are  congested  and  exhibit  uric  acid  infarcts 
and  sometimes  infarcts  of  biliary  coloring  matter,  and  the  latter  have 
also  been  found  in  the  brain. 

Symptoms. — The  discoloration  begins  oftenest  on  the  2d  or 
3d  day  of  life;  much  less  often  earlier  or  later  than  this.  The  surface 
of  the  body  is  the  region  most  markedl}^  affected,  but  in  most  cases  the 
sclerse  are  also  involved.  The  mucous  membranes  also  are  icteric.  The 
discoloration  is  first  noticed  on  the  face  or  chest,  and  its  degree  varies 
greatly.  Sometimes  it  is  intense,  but  often  it  is  very  slight  and  can  only 
be  appreciated  in  good  daylight  and  after  the  red  color  of  the  skin  is 
removed  temporarily  by  pressure  with  the  finger.  The  urine  is  generally 
free  from  bile-pigment,  at  least  by  ordinary  tests,  although  the  micro- 
scope may  sometimes  reveal  masses  of  biliary  pigment.  There  is  an  in- 
crease in  the  excretion  of  urea  and  uric  acid  (Hofmeier).''  The  stools  are 
unaltered  in  character.     The  pulse,  respiration  and  temperature  of  the 

1  Zeitschr.  f.  Ivinderli.,  Orig.,  1913,  IX,  208. 

2  Zeitschr.  f.  Kinderh.,  Grig.,  1913,  IX,  198. 
•^  Arner.  Jour.  Dis.  Child.,  1912,  III,  304. 

*  (Icrhardt's  Handb.  d.  Kinderkr.,  IV,  2,  691. 
'"  KHnik  d.  Leberkrank.,  1858,  I,  199. 
«  Arch.  f.  exper.  Path.  u.  Therap.,  1885,  XIX,  34. 
'  Zeitsch.  f.  Geburtsh.  u.  Gvn..  1882,  Vlll,  287. 


276  THE  DISEASES  OF  CHILDREN 

child  are  entirely  unaffected,  and  the  liver  and  spleen  are  not  enlarged. 
Regarding  the  influence  of  the  disease  on  the  general  health  and  nutrition 
there  is  some  dispute.  The  majority  of  statistics  certainly  indicate  that 
there  occurs  a  greater  loss  of  weight  and  a  slower  regain  of  it  when  icterus 
is  present,  but  it  is  uncertain  whether  the  slow  gain  is  not  rather  the 
cause  than  the  result  of  the  icterus. 

The  duration  is  about  3  or  4  days  in  the  milder  cases.  In  the  severer 
forms  it  may  be  2  weeks  or  more  before  all  traces  of  the  icterus  have 
disappeared,  but  in  these  long-continued  cases  it  is  always  questionable 
whether  the  condition  does  not  depend  upon  some  other  cause. 

Diagnosis. — The  distinction  is  to  be  made  between  icterus  neo- 
natorum and  the  various  forms  of  symptomatic  icterus.  This  is  to  be 
done  in  part  by  the  presence  of  other  symptoms  in  the  latter  condition. 
Then,  too,  in  symptomatic  icterus  the  urine  is  more  liable  to  be  visibly 
discolored  by  the  bile-pigment.  In  cases  of  decided  obstructive  jaundice 
the  stools  show  an  absence  of  bile.  A  very  slight  degree  of  discoloration 
of  the  skin  speaks  rather  for  icterus  neonatorum,  while  a  late  development 
of  it  indicates  some  other  cause.  Yet  an  early  diagnosis  is  often  impossi- 
ble. This  is  especially  true  in  slight  cases  of  catarrhal  icterus  due  to  duo- 
denal catarrh;  and  still  more  in  the  instances  in  which  icterus  neonatorum 
happens  to  be  combined  with  other  diseases  of  the  new  born;  such,  for 
instance,  as  sepsis.  Congenital  obliteration  of  the  bile-ducts  gives  rise 
to  an  intense  icterus  developing  very  promptly  after  birth  and  persisting. 
Certain  severe  cases  of  congenital  icterus  will  be  discussed  later.  (See 
Digestive  Diseases,  p.  836.)  Such  infants  are  distinctly  ill,  and  the  icterus 
is  accompanied  by  other  signs,  sometimes  of  a  hemorrhagic  nature. 

Treatment. — Nothing  is  needed,  and  nothing  can  be  done  for  the 
ordinary  average  case.  Time  will  cure  it.  The  ordinary  care  should  be 
taken  to  keep  the  functions  of  the  organism  in  good  order. 


CHAPTER  VII 
ASPHYXIA  NEONATORUM 

The  term  Asphyxia,  or  Suffocation,  as  applied  to  the  new  born 
indicates  a  condition  in  which,  although  the  heart's  action  continues, 
the  supply  of  oxygen  to  the  blood  ceases,  and  respiratory  movements 
after  birth  are  either  absent  or  insufficient  to  overcome  this  lack. 

Etiology. — The  disease  may  either  be  (1)  of  intra-uterine  or  (2)  of 
extra-uterine  origin,  the  latter  being  nmch  less  frequent.  The  distinction 
depends  on  whether  or  not  the  circulation  through  the  placenta  has  been 
interfered  with. 

(A)  Intra-uterine  Asphyxia. — This  develops  before  or  during  birth, 
and  is  due  to  some  interruption  of  the  normal  interchange  of  gases  in  the 
placenta.  Among  maternal  causes  which  interfere  with  the  placental 
circulation  may  be  mentioned  excessive  uterine  contraction,  unduly  pro- 
longed labor,  uterine  hemorrhage,  and  severe  complicating  illness  or  the 
death  of  the  mother.  On  the  side  of  the  child  are  such  factors  as  detach- 
ment of  the  placenta,  compression  of  the  brain  interfering  with  the  action 
of  the  heart,  and  compression  of  the  umbiUcal  cord.  Efforts  at  intra- 
uterine respiration  occur  in  most  cases  as  a  result  of  the  undue  stimulation 
of  the  respiratory  centres;  but  whether  this  stimulation  is  the  result  of 


ASPHYXIA  NEONATORUM  277 

the  overloading  of  the  blood  with  carbonic  dioxide  or  of  the  deprivation  of 
oxygen  is  not  yet  certainly  determined.  The  consequent  filling  of  the 
respiratory  passages  with  fluid  increases  the  danger  to  the  infant  after 
birth  has  occurred.  In  cases,  however,  where  the  asphyxia  has  developed 
slowly,  the  respiratory  centres  have  sustained  a  paralyzing  action,  and 
efforts  at  breathing  have  not  taken  place. 

It  is  evident  that  the  likelihood  of  the  occurrence  of  intra-uterine 
asphyxia  must  increase  with  the  duration  of  labor,  especially  of  its  second 
stage.  The  statistics  of  Veit^  show  very  strikingly  that  the  mortality 
from  asphyxia  after  a  second  stage  of  4  hours  or  more  was  over  3  times 
as  great  as  when  it  had  lasted  but  1  hour. 

(B)  Extra-uterine  Asphyxia  {Atelectasis  Pulmonum)  .—The  child  is 
born  without  any  evidence  of  asphyxia,  but  develops  it  soon  after  birth 
from  some  of  the  numerous  causes  which  interfere  with  the  gaseous 
interchange.  Among  these  may  be  mentioneed  interference  with  the 
access  of  air,  as  by  maternal  discharges  or  unruptured  membranes; 
malformation  of  the  diaphragm;  intra-uterine  pneumonia  or  pleural  effu- 
sion interfering  later  with  the  action  of  the  lungs;  malformation  of  the 
lungs;  severe  injuries  to  the  brain  at  the  moment  of  birth,  which  after- 
ward affect  the  action  of  the  respiratory  centres;  malformation  of  the 
heart,  which  renders  the  carrying  of  oxygenated  blood  impossible;  etc. 
Premature  birth  is  a  very  potent  cause  of  extra-uterine  asphyxia,  the 
active  factor  being  the  general  feebleness  of  the  child,  the  weakness  or 
imperfect  development  of  the  respiratory  nerve-centres,  or  a  similar 
condition  of  the  muscles  and  bones  of  the  chest-wall  or  of  the  lungs 
preventing  satisfactory  pulmonary  or  thoracic  expansion. 

.  Pathological  Anatomy. — The  lesions  found  are  those  characteristic 
of  suffocation.  The  blood  is  fluid  and  of  a  dark  color.  The  heart, 
especially  the  right  chambers,  is  overfilled  with  blood.  The  blood-ves- 
sels in  general  are  distended,  and  all  the  internal  organs  congested.  The 
liver  is  of  a  dark  bluish-red  color.  Numerous  punctiform  or  larger  hemor- 
rhages may  be  found  in  nearly  any  of  the  organs  of  the  body.  Bloody 
serous  fluid  is  present  in  the  serous  cavities.  There  is  often  the  escape 
of  a  considerable  amount  of  blood  into  the  intestines. 

If  the  child  has  made  attempts  at  inspiration  while  still  in  the  uterus, 
mucus,  bloody  amniotic  fluid  or  meconium  may  be  found  in  the  larynx, 
trachea  and  larger  bronchi;  less  often  in  the  finer  bronchi  and  the  alveoli. 
The  lungs  are  very  dark  red,  heav.y,  much  congested  and  of  uniform 
atelectatic  appearance  when  there  has  been  no  entrance  of  air.  This 
intense  congestion  is  evidence  that  intra-uterine  efforts  at  respiration 
have  probably  taken  place.  If  air  has  entered  to  some  extent,  either 
through  the  infant's  own  efforts  or  as  a  result  of  the  employment  of 
artificial  respiration,  small  scattered  areas  of  distended  pulmonary  tissue 
will  be  visible,  especially  in  the  upper  lobes. 

Symptoms.  (A)  Intra-uterine  Asphyxia. — In  asphyxia  of  intra- 
uterine origin  certain  symptoms  discoverable  before  birth  make  the 
diagnosis  very  probable.  There  occurs  in  the  intervals  between  the 
labor  pains  a  retardation  of  the  fetal  heart-sounds.  Finally,  if  deUvery 
does  not  occur,  the  sounds  grow  more  irregular,  rapid,  and  weak,  and 
then  cease  altogether.  A  suspicious,  although  not  entirely  diagnostic, 
symptom  in  vertex  presentations  is  the  discharge  from  the  maternal 
vagina  of  meconium  which  has  just  been  passed  >  by  the  infant,  as  a 

1  Monatssc'h.  f.  Geburtsk.,  1805,  W,  11-'. 


278  THE  DISEASES  OF  CHILDREN 

result  of  the  increased  intestinal  peristalsis  that  asphyxia  produces.  The 
intra-uterine  movements  of  the  child  may  become  more  active.  Excep- 
tionally in  breach  presentations,  convulsive  movements  of  the  body 
may  be  noticed.  Sometimes,  too,  intra-uterine  efforts  at  respiration 
may  occasionally  be  detected  by  the  finger  inserted  into  the  infant's 
mouth. 

In  the  case  of  new-born  healthy  children  respiration,  followed  by  a 
vigorous  cry,  begins  at  once,  or  at  the  most  after  a  very  few  seconds.  In 
asphyxiated  children,  on  the  other  hand,  either  no  respiratory  efforts  at 
all  are  noticed  after  birth,  or  only  imperfect  and  intermittent  ones.  The 
body  is  motionless  and  the  child  appears  to  be  dead  except  for  the  con- 
tinued action  of  the  heart. 

Two  degrees  of  asphyxia  of  intra-uterine  origin  are  observed :  a  milder 
form,  asphyxia  livida  and  a  severer  form  asphyxia  pallida.  The  symptoms, 
prognosis  and  treatment  of  the  two  are  very  different. 

1.  Asphyxia  Livida. — In  this  milder  form  the  skin  is  dark  bluish-red  in 
color,  the  heart's  action  is  strong  although  decidedly  slow,  and  the  pulse 
in  the  umbilical  cord  is  full  and  strong  and  the  tension  high.  The  con- 
junctivae are  injected,  and  the  face  turgid.  Respiratory  efforts  are  absent 
or  occur  only  occasionally,  and  at  first  very  superficially,  and  are  attended- 
by  a  contortion  of  the  face.  Coarse  rales  are  audible  in  the  lungs. 
Stimulation  of  the  skin  causes  an  energetic  inspiratory  effort,  and  the 
finger  introduced  into  the  mouth  for  the  purpose  of  cleansing  it  produces 
attempts  at  vomiting  or  swallowing.  A  very  characteristic  symptom  of 
asphyxia  livida  is  that  the  muscle-tonus  is  preserved;  i.e.  although  the 
child  is  motionless,  yet  it  is  not  absolutely  flaccid  when  it  is  lifted. 

2.  Asphyxia  Pallida. — In  this  variety  the  skin  is  pale  and  corpse-like, 
and  the  heart's  action  very  weak  and  usually  rapid.  The  vessels  in  the 
cord  appear  to  be  empty,  and  the  pulse  there  is  entirely  absent  or  extremely 
feeble.  Generally  there  are  no  true  respiratory  efforts,  and  any  occasional 
attempts  at  inspiration  which  may  occur  seem  to  depend  entirely  on  the 
action  of  the  diaphragm,  the  thorax  moving  not  at  all,  and  no  grimace  of 
the  face  attending  them.  No  rales  can  be  heafd;  this  showing  that  the 
efforts  at  inspiration  have  been  absent  or  entirely  futile.  Stimulation 
of  the  skin  is  without  result,  and  the  finger  in  the  pharynx  produces 
no  reflex  movements  of  its  muscles  or  of  the  palate.  The  great  charac- 
teristic of  this  grade  of  asphyxia  is  complete  loss  of  muscle-tonus.  The 
child  is  absolutely  limp,  the  jaws  fall,  the  head  drops  completely  in  some 
direction  if  the  child  is  lifted,  and  the  anus  is  open. 

(B)  Extra -UTERINE  Asphyxia. — In  asphyxia  of  extra-uterine  origin 
the  symptoms  vary  somewhat,  depending  upon  the  cause.  The  skin  is 
usually  dark  reddish-blue.  The  heart's  action  is  strong,  and  the  vessels 
of  the  cord  are  filled  with  blood.  The  pulse,  however,  is  not  at  first 
slow,  and  although  it  later  becomes  so,  it  finally  commonly  grows  rapid 
again.  This  distinguishes  the  condition  from  intra-uterine  asphj^xia. 
Respiration  is  wanting  or  occasional  only,  and  is  not  attended  by  rales. 
This  lack  of  rales  shows  the  absence  of  fluid  from  the  respiratory  tract, 
an  evidence  that  the  condition  is  extra-uterine  in  nature.  In  asphyxia  in 
premature  infants  respiration  may  continue  irregular  and  very  superficial 
for  days,  and  is  almost  entirely  diaphragmatic.  The  children  lie  for 
the  most  part  with  eyes  closed,  motionless  and  somnolent,  and  make  no 
sound  or  only  occasionally  utter  a  feeble  cry.  The  face  is  dark  red  and 
somewhat  swollen;  edema  of  the  extremities  and  scrotum  develops;  the 
temperature  is  subnormal;  there  is  loss  of  weight.     In  marantic  infants 


ASPHYXIA  NEONATORUM  279 

who  have  passed  the  age  generally  allotted  to  the  new  born,  as  well  as 
later  in  badly  rachitic  subjects,  asphyxia  is  of  not  infrequent  occurrence. 
It  is  the  result  of  atelectasis,  and  its  symptoms  are  those  of  the  extra- 
uterine form  developing  earlier  in  life. 

Course  and  Prognosis. — Unless  treated  there  is  probably  httle 
tendency  for  cases  of  asphyxia  to  recover.  Asphyxia  livicla,  when  not 
excessive,  will  nearly  always  yield  quickly  to  appropriate  treatment.  In 
the  course  of  a  few  seconds  or  possibly  minutes  respirations  become  more 
frequent  and  effective,  and  are  finally  succeeded  by  loud  crying.  Many 
children,  however,  pass  from  the  milder  form  into  the  severer  degree. 
The  result  in  asphyxia  pallida  is  always  more  doubtful.  The  duration 
is  variable.  Some  children  die  almost  immediately,  while  others  may 
continue  for  hours  without  any  apparent  change;  or,  after  improvement 
begins,  may  relapse  if  treatment  is  not  persisted  with.  If  recovery 
ensues  intermittent  and  occasional  respirations  begin  and  are  perhaps 
followed  by  a  slight  cry,  and  finally  satisfactory  breathing  is  established. 
The  longer  the  duration  of  the  second  stage  of  labor,  the  worse  is  the 
prognosis.  The  prognosis  is  graver,  too,  in  proportion  to  the  weakness  of 
the  pulse  or  of  the  heart-sounds.  The  presence  of  any  complication,  such 
as  intracranial  hemorrhage  or  acute  fatty  degeneration,  likewise  makes 
the  prognosis  unfavorable.  Yet  even  in  the  severer  grades  of  intra-uter- 
ine  asphyxia  the  majority  of  infants  will  recover.  Even  those  who  have 
seemed  hopeless,  and  who  for  hours  have  appeared  to  be  dead  may  still 
survive.  Asphj^xia  of  extra-uterine  origin  generally  runs  a  rapid  course 
if  dependent  upon  some  malformation  or  some  disease  of  the  respiratory 
apparatus.  When  the  result  of  premature  birth,  it  may  continue,  as 
stated,  for  days. 

Regarding  the  after-effects  of  the  disease  upon  a  child  who  has  sur- 
vived, it  has  been  maintained  that  long-continued  severe  asphyxia  is 
liable  to  produce  idiocy  or  paralytic  conditions.  Although  it  seems  more 
probable  that  such  disorders  are  the  result  of  some  injury  to  the  brain  at 
birth,  of  which  the  respiratory  condition  was  but  a  symptom,  yet  it  is 
possible  that  the  congestion  accompanying  the  asphyxia  may  have  pro- 
duced the  breaking  of  blood-vessels  within  the  cranium,  and  thus  have 
become  the  first  cause  of  later  nervous  or  mental  disorders.  It  may 
happen,  too,  that  aspiration-pneumonia  may  develop  in  an  infant  after 
its  recovery  from  asphyxia. 

Diagnosis. — The  milder  grade  of  asphyxia  may  be  confounded 
with  compression  of  the  brain  by  hemorrhage.  Meningeal  hemorrhage 
may  indeed  produce  symptoms  resembling  those  of  asphj'xia  very  closelj', 
and  as  the  latter  condition  may  be  one  of  the  sjanptoms  of  the  former, 
the  object  of  diagnosis  is  to  determine  whether  or  not  asphyxia  is  actually 
present,  and,  if  so,  whether  it  depends  on  an  intracranial  compression. 
Compression  produces  slowing  of  the  pulse  and  irregularity  of  respiration. 
If  a  child  exhibits  at  birth  the  symptoms  of  the  milder  degree  of  asphyxia 
and,  instead  of  responding  quickly  to  treatment,  does  so  not  at  all,  or 
but  temporarily  or  imperfectly,  while  the  slowness  of  the  pulse  persists, 
the  existence  of  a  complicating  meningeal  hemorrhage  is  very  probable. 
This  is  true  also  if  the  child  is  l)orn  without  evidence  of  asphyxia,  but 
soon  passes  into  this  condition,  witli  slow  pulse,  slow  irregular  respiration, 
coma,  and  bulging  fontanelle.  In  other  cases  there  is  marked  asphyxia 
from  the  beginning  and  the  diagnosis  must  for  a  time  remain  in  doubt. 
The  presence  of  paralysis  renders  the  diagnosis  of  hemorrhage  positive. 
The  history  of  the  case  aids  in  the  recognition  of  compression;  as,  for 


280  THE  DISEASES  OF  CHILDREN 

instance,  when  the  labor  has  been  unduly  prolonged,  the  pelvis  narrow, 
or  forceps  applied. 

Intense  anemia  resulting  from  severe  hemorrhage  may  simulate 
asphyxia  pallida  closely.  The  presence  of  rales,  if  a  respiration  occurs, 
is  an  indication  that  intra-uterine  efforts  at  breathing  have  taken  place 
and  that  asphyxia  exists.  The  history  is  of  the  greatest  diagnostic 
value,  for  only  the  tearing  of  the  umbilical  cord  during  birth  can  produce 
a  hemorrhage  which  is  sufficient  to  account  for  so  great  a  degree  of  anemia. 

Asphyxia  may  be  complicated  by,  or  be  the  only  symptom  of,  acute 
fatty  degeneration  of  the  new  horn.  In  such  cases  the  issue  is  fatal,  and  the 
microscopic  examination  makes  the  diagnosis  clear. 

Treatment.  {A)  Asphyxia  of  Intra-uterine  Origin. — The  condi- 
tion should  be  prevented  as  far  as  may  be  b}^  employing  such  measures  as 
will  obviate  unduly  prolonged  delivery  and  in  every  other  respect  maintain 
the  labor  in  as  normal  a  condition  as  possible.  Evidences  of  asphyxia 
developing  during  labor  must  be  carefully  watched  for.  The  subject 
is  treated  of  in  works  upon  obstetrics. 

Whatever  the  degree  of  asphyxia  present  after  the  birth  of  the  infant 
the  first  indication  is  to  free  the  respiratory  passages  as  far  as  possible. 
A  finger  should  be  introduced  into  the  mouth  and  pharynx  in  order  to  , 
remove  any  mucus  or  fluid  present.  The  child  may  also  be  suspended 
with  head  downward  for  a  moment  in  order  to  favor  discharge  of  fluid, 
and  to  produce  a  congestion  and  stimulation  of  the  respiratory  centres, 
and  the  body  be  slapped  smartly  with  the  open  hand.  In  the  case  of 
asphyxia  livida,  if  well  marked,  the  cord  may  be  severed  at  once,  and  3^^ 
ounce  (15)  or  less  of  blood  allowed  to  escape.  The  child  may  then  be 
slapped  with  a  cold,  wet  towel  or  plunged  into  cold  water  in  order  to 
stimulate  respiration  by  cutaneous  irritation.  It  must  then  immediately 
be  put  into  a  hot  bath.  This  procedure,  involving  the  alteration  of  hot 
and  cold  water,  may  be  quickly  repeated  as  often  as  necessary.  Efforts 
at  respiration  are  generally  produced  by  the  cold  water.  These  are 
attended  by  fresh  accumulations  of  mucus  in  the  throat  necessitating 
repeated  cleansing  of  this  in  the  manner  mentioned.  Sometimes  a 
single  application  of  cold  will  suffice.  In  other  cases  we  must  continue 
perhaps  a  half  hour  before  all  evidences  of  abnormal  color  have  disap- 
peared, and  the  infant  is  breathing  well  and  crying  lustily. 

In  asphyxia  pallida,  or  in  those  cases  of  asphyxia  livida  in  which  the 
treatment  described  does  not  quickly  produce  some  decided  efforts  at 
respiration,  valuable  time  is  lost  by  employing  it.  In  the  latter  form  of 
the  disease  the  child  has  passed  the  stage  where  cutaneous  stimulation 
can  produce  any  effect  whatever,  and  in  the  former  the  permitting  of  a 
flow  of  blood  from  the  cord  can  do  only  harm.  The  cord  should  be  ligated 
and  cut  promptly,  and  artificial  respiration  commenced  at  once.  What- 
ever means  are  employed  an  artificial  expira.tion  should  be  sought  first, 
in  order  to  remove  aspirated  fluid  from  the  respiratory  tract.  If 
inspiration  occurs  first  the  fluid  is  drawn  still  further  into  the  lungs.  The 
method  of  Schultze  is  that  most  in  vogue.  ^  The  physician  grasps  the 
child  with  both  hands  in  such  a  way  that  his  thumbs  rest  loosely  on  the 
front  of  the  child's  thorax,  his  first  fingers  pass  from  behind  into  the  axilla, 
and  the  remaining  fingers  are  spread  over  the  back  of  the  child.  The  in- 
fant's head  rests  against  his  forearms  and  hands.  Standing  with  knees 
somewhat  apart,  and  having  the  child  hanging  feet  downward  and  face 
forward,  he  now  swings  the  body  forward  and  upward,  exercising  no  com- 
1  Der  Scheintod  d.  Neugeborencn,  1871. 


ASPHYXIA  NEONATORUM 


281 


pression  with  the  fingers,  until  his  arms  are  somewhat  above  the  horizon- 
tal position.  The  swing  now  ceasing,  momentum  carries  the  lower  part 
of  the  child  slowly  forward,  throwing  the  legs  up  and  over  toward  the 
physician,  while  the  head  hangs  down.  The  trunk  becomes  in  this  way 
strongly  flexed,  and  the  abdomen  and  chest  consequently  compressed, 
the  weight  of  the  child  resting  against  the  physician's  thumbs.  This 
pressure  causes  an  enforced  expiration,  and  the  aspirated  fluid  may  be 
driven  from  the  mouth  and  nose.  After  a  pause  of  a  few  seconds  the 
child  is  again  swung  downward  into  the  original  position.  All  pressure 
being  thus  removed  from  the  chest,  an  enforced  inspiration  follows.  In 
a  few  seconds  more  the  movements  are  repeated,  and  so  on  for  6  or  8 
times  in  the  course  of  a  minute  or  less,  after  which  the  child  is  placed  in 
a  tub  of  warm  water  for  a  few  minutes.  If  no  natural  respiratory  move- 
ments have  commenced,  the  whole  process  is  repeated  (Fig.  47). 


Fig.  47. — Schultze's  Method  of  Artificial  Respiration. 
(a)  Inspiration;  (h)  expiration.     (B.  C.  Hirst,  Obstetrics,  6th  Ed.  958.) 

It  is  important  that  the  inversion  of  the  child  in  the  production  of 
expiration  should  occur  slowlj^,  in  order  that  the  flexion  of  the  spine  may 
take  place  in  the  lum])ar  region  and  not  above  this.  The  first  part  of  the 
swing  upward  is  quickly  made,  the  latter  part  more  slowh'.  The  neck 
must  always  be  kept  from  flexing  in  order  to  permit  free  entrance  of  air. 
Any  compression  by  the  hands  must  be  carefully  avoided  at  every  stage. 
The  movements,  though  performed  thoroughly,  must  always  be  done 
gently  and  skilfully.  The  method  requires  some  practice  to  be  carried 
out  properly.  If  the  swinging  movements  have  succeeded  in  starting 
respiration  and  increasing  tiie  power  of  the  heart's  action,  the  case  has 
now  become  one  of  the  milder  degree  of  asphyxia,  and  cutaneous  stimu- 
lation may  be  tried.  If  it  has  not  succeeded  artificial  respiration  nmst 
be  used  again  and  again.  It  should  be  persisted  with  as  long  as  the  heart 
continues  to  beat,  even  for  hours  if  necessary. 

It  is,  in  fact,  very  important  not  to  abandon  too  soon  this  or  any 
other  metliod  of  resuscitation  which  is  employed.  A  few  efforts  at  respi- 
ration by  the  infant,  or  a  single  cry,  do  not  constitute  recovery,  as  relapse 
is  very  liable  to  occur.     Easy  respiration  must  be  fully  estabhshed,  the 


282  THE  DISEASES  OF  CHILDREN 

normal  color  must  return,  the  extremities  move,  and  the  child  cry  well 
and  open  its  eyes  before  the  physician  may  feel  content.  Very  careful 
supervision  is  necessary  after  respiration  seems  established.  Small 
doses  of  alcohohc  and  other  cardiac  stimulants  are  useful,  as  well  as 
careful  protection  against  chilling  by  the  use  of  cotton  wrappings  and 
hot-water  bags. 

Weakly  infants  with  great  debility  of  the  heart's  action  may  not  well 
tolerate  the  Schultze's  treatment,  or  the  chest  walls  may  be  so  yielding 
that  inspiration  does  not  occur.  In  other  instances  the  presence  of  such 
injuries  as  fractures,  especially  of  the  arms  or  clavicles,  interferes  with  the 
use  of  the  method,  and  always  there  is  the  difficulty  in  avoiding  chiUing. 
In  place  of  it  the  direct  inflation  of  the  lungs  may  be  tried.  Mouth-to- 
mouth  inflation  is  an  old  method,  which  may  be  employed  in  emergency, 
a  clean  towel  being  placed  between  the  mouth  of  the  child  and  that  of 
the  physician  and  only  the  first  part  of  the  expired  air  from  the  physician 
blown  into  the  child.  The  nostrils  should  not  be  compressed.  If  this 
does  not  succeed  a  soft  rubber  catheter  may  be  passed  into  the  larynx, 
and,  after  fluid  aspirated  by  the  child  has  been  withdrawn  by  suction  by 
the  mouth  or  by  a  rubber  bulb  attached  to  the  tube,  air  may  be  forced 
into  the  lungs  and  again  drawn  out,  aided  by  pressure  of  the  hand  upon 
the  thorax.  This  should  be  continued,  using  fresh  air  at  each  inflation 
until  respiration  is  established.  The  method  is  not  without  objections, 
for  not  only  is  it  difficult  to  pass  the  tube  into  the  larynx  instead  of  the 
esophagus,  but  too  great  pressure  may  easily  over-distend  the  lungs  and 
produce  emphysema  or  even  rupture  of  the  vesicles.  A  more  scientific 
modification  of  this  is  the  furnishing  of  a  continuous  supply  of  air,  as 
used  in  animal  experimentation,  and  the  employing  of  a  manometer  to 
guard  against  too  high  a  pressure. 

Numerous  modifications  of  or  substitutions  for  Schultze's  method 
have  been  proposed,  some  of  them  antedating  it.  Among  these  may  be 
mentioned  those  of  Marshall  Hall^  and  of  ^ylvester^  as  used  for  the  re- 
covery of  persons  from  drowning,  and  the  method  of  resuscitation  recom- 
mended by  Laborde.  ^  This  latter  consists  in  grasping  the  tip  of  the  tongue, 
wrapped  about  with  gauze,  and  making  rhythmic  traction  on  it  8  to  12 
times  a  minute.  It  is  a  powerful  awakening  of  respiratory  efforts  if  there 
is  any  reflex  excitability  remaining  in  the  nervous  supply  of  the  tongue. 
Its  advantage  over  Schultze's  method  is  that  it  can  be  used  while  the  child 
is  kept  in  the  warm  bath.  According  to  Dew's  method'*  the  left  hand  of 
the  physician  grasps  the  infant  by  the  back  of  the  neck  and  the  right  hand 
the  knees,  the  body  and  thighs  resting  upon  the  palms.  The  lower 
extremities  and  abdomen  are  now  flexed  upon  the  thorax  and  head  pro- 
ducing expiration,  and  the  body  and  head  then  extended  into  a  backward 
curve  to  bring  about  inspiration.  This  seems  to  be  practically  identical 
with  the  method  of  Byrd,^  which  consisted  in  letting  the  child  lie  with  its 
back  upon  the  palmar  surface  of  the  physician's  two  hands.  The  body 
is  then  flexed,  biinging  the  head  and  feet  close  together  and  forcing  the 
air  from  the  chest.  A  movement  of  over-extension  in  the  opposite  direc- 
tion tends  to  produce  inspiration.     A  similar  procedure  is  recommended 

1  Lancet,  1856,  II,  124. 

2  Brit.  Med.  Journ.,  1858,  576. 

^  Les  tractions  rhythmique  de  la  langue,  1897. 
'  Koplik,  Dis.  of  Inf.  and  Childh.,  1910,  196.      ' 
6  Baltimore  Med.  Journ.,  1870,  I,  046. 


ASPHYXIA  NEONATORUM 


283 


by  Ssokolow^  (Fig.  48),  the  head  being  allowed  to  flex  toward  the  spine 
during  the  extension  of  the  body.  These  methods  have  the  advantage 
that  the  infant  can  be  kept  in  the  warm  bath  much  of  the  time.  Alin- 
kevitch^  places  the  infant  on  its  back,  with  the  hand  of  the  physician  in 
each  axilla,  and  alternately  bends  the  trunk  forward  between  the  sepa- 
rated legs,  and  extends  it  again  into  the  horizontal  position,  while  Rosen- 
thaP  flexes  the  knees  upon  the  breast  with  the  infant  similarly  placed. 
Prochownik'*  advises  that  the  child  be  held  inverted  while  an  assistant 


Fio.  48. — Method  for  Inducing  Artificial  Respiration  in  the  Newborn. 
(a)  Inspiration;  (6)  expiration.     (_Afler  Ssokolow,  Monalssckr.  /.  Kindcrh.,  Orig.,  1011, 
X,  459.) 

alternately  compresses  and  releases  the  thorax;  Zangenmeister^  recom- 
mends forced  inhalation  of  oxygen  through  a  tracheal  catheter  fitted  with 
a  bulb;  and  La  llue*^  claimed  good  results  in  re-establishing  cardiac  ac- 
tion by  massage  of  the  heart  by  the  thumbs  over  the  precordial  area. 

1  Monatsschr.  f.  Kindrrli.,  OriR.,  1911,  X,  457. 

^Seniaine  m6d.,  1902,  XXII,  :J72. 

3  Therap.  Monatsh.,  1893,  VII,  5.5. 

*  Centralbl.  f.  Gyiiak.,  1894,  XVI II,  225. 

'Centralbl.  f.  (ivniik.,  190:i.  XXVII,  11(12. 

'Pediatrics,  1914,  XXVI,  12G. 


284  THE  DISEASES  OF  CHILDREN 

(B)  Asphyxia  of  Extra-uterine  Origin. — Treatment  is  of  little 
avail  where  the  asphyxia  results  from  anomalies  of  respiration  or  of  cir- 
culation, or  from  intra-uterine  diseases.  When  it  depends  upon  the  ex- 
istence of  premature  birth  there  become  necessary  certain  modifications  of 
the  methods  already  detailed.  Not  only  is  the  relief  of  the  asphyxia 
required,  but  that  treatment  also  which  has  been  described  as  appropriate 
for  premature  birth  (p.  255).  The  removal  of  aspirated  fluid  from  the 
mouth  is  not  usually  needed,  since  intra-uterine  efforts  at  respiration  have 
not  taken  place.  When  the  case  is  one  unsuited  for,  or  not  benefited 
by,  cutaneous  stimulation,  artificial  respiration  must  be  attempted.  How- 
ever, the  weakness  of  the  child  and  the  lack  of  elasticity  of  the  chest-wall, 
together  with  the  great  need  for  maintaining  bodily  heat,  render  Schultze's 
method  in  many  cases  inapplicable  or  unavailing,  and  some  of  the 
procedures  to  be  preferred  which  permit  of  the  constant  maintenance  of 
bodily  temperature  in  a  warm  bath.  The  very  great  liability  of  these 
cases  to  relapse  is  not  to  be  forgotten.  Close  watching  is  required, 
and  if  the  tendency  appears,  warm  baths  and  cutaneous  friction  should 
be  employed  several  times  daily  in  order  to  interrupt  the  somnolence 
and  produce  vigorous  crying.  Days  may  p^ass  before  either  the  safety 
of  the  child  is  assured  or  death  takes  place. 


CHAPTER  VIII 
PULMONARY  ATELECTASIS  IN  THE  NEW  BORN 

Etiology. — The  name  denotes  a  persistence  of,  or  a  return  to,  the 
unexpanded  fetal  condition  of  the  lung.  It  is  peculiarly  a  disease 
of  the  new  born,  although  under  certain  circumstances  it  may  develop 
in  older  subjects.  This  acquired  atelectasis  will  be  considered  later  (Vol. 
II,  p.  94).  In  some  cases  the  infants  are  born  asphyxiated,  respiration 
is  absent  or  incomplete,  and  the  lung  never  expands  properly  even  under  the 
influence  of  artificial  respiration.  The  asphyxia  and  the  atelectasis 
may  then  be  regarded  as  due  to  the  same  cause.  (See  Asphyxia,  p.  276.) 
In  other  instances,  especially  in  premature  children,  or  those  who  are 
weakly  from  other  reasons,  respiration  is  established  for  a  time  and  there 
is  at  first  no  evidence  of  asphyxia.  Soon,  however,  the  poorly  distended 
lungs  become  gradually  more  and  more  collapsed,  owing  to  the  weakness 
of  the  child  and  the  yielding  character  of  the  thorax,  which  make  satis- 
factory respiration  difficult  or  impossible.  Asphyxia  then  develops 
as  the  result  of  the  atelectasis. 

Pathological  Anatomy. — In  complete  atelectasis,  where  the  infant 
has  never  breathed,  the  lungs  are  dark-red  or  blue-red,  small,  very 
vascular,  entirely  collapsed,  firm  to  the  touch,  do  not  crepitate,  and 
sink  in  water.  They  are  capable,  however,  of  being  forcibly  inflated 
without  difficulty,  thus  distinguishing  the  condition  from  pneumonic 
consolidation.  If  the  lungs  have  been  partially  inflated  during  life, 
either  through  respiratory  efforts  of  the  infants  or  through  attempts 
at  artificial  respiration,  post-mortem  examination  shows  small  scattered 
areas  of  normally  distended  or  emphysematous  pulmonary  tissue,  char- 
acterized by  the  lighter  color  and  the  evident  presence  of  air.  These 
are  oftenest  seen  in  the  upper  portion  of  the  lung  or  at  the  anterior  edges. 
Where  life  has  continued  some  weeks  the  anterior  parts  of  the  lungs  may 


PULMONARY  ATELECTASIS  IN  THE  NEW  BORN  285 

be  found  entirely  distended  or  even  emphysematous,  while  the  posterior 
portions,  especiallj^  the  lower  lobes,  are  completely  atelectatic,  or  perhaps 
the  surface  seems  normal  but  the  portions  beneath  it  are  collapsed  and 
the  lung  is  hard.  There  is  a  striking  contrast  between  the  areas  of 
healthy  or  distended  lung  and  the  depressed,  dark,  atelectatic  portions. 
Both  lungs  are  generally  involved,  although  not  necessarily  equally  so. 
Quite  frequently  more  or  less  hypostatic  pneumonia  is  combined  with 
the  atelectasis.  In  some  cases  one  area  may  be  pneumonic  and  another 
atelectatic.     Other  lesions  are  those  described  under  Asphyxia. 

Symptoms. — In  the  cases  in  which  the  children  are  asphyxiated 
at  birth,  and  either  show  little  or  no  tendency  to  recovery  or  relapse 
promptly,  the  symptoms  of  atelectasis  are  those  already  described 
under  Asphyxia.  In  those  in  which  the  atelectasis  develops  later, 
being  dependent  upon  the  excessive  weakness  of  the  infant,  or  in  which 
asphyxia,  although  present  at  birth,  has  apparently  been  recovered  from, 
the  symptoms  of  atelectasis  are  characteristic.  The  pulse  is  weak  and 
slow;  the  respiration  is  rapid,  irregular  and  shallow,  and  attended  by 
evident  retraction  of  the  intercostal  spaces  and  the  lower  portion  of 
the  thorax  at  the  insertion  of  the  diaphragm.  The  infant  is  somnolent 
and  lies  generally  with  eyes  closed,  crying  but  little  and  never  loud,  and 
making  feeble,  if  any,  efforts  to  suck.  The  temperature  of  the  body 
is  persistently  or  only  at  times  subnormal.  The  physical  examination 
of  the  lungs  generally  gives  a  somewhat  impaired  percussion  noted  over 
the  lower  posterior  portion  of  the  chest.  Sometimes,  however,  no  dis- 
tinct alteration  of  note  can  be  discovered  if  numerous  inflated  areas  of 
pulmonary  tissues  are  present.  The  respiratory  murmur  is  feeble, 
with  fine  rales  at  times,  but  as  a  rule  no  bronchial  breathing  is  discovered. 

This  condition  may  continue  for  weeks.  Recovery  may  take  place 
after  several  relapses,  or  death  may  occur  suddenly,  often  with  convul- 
sions and  without  there  having  been  any  very  positive  sign  which  indicated 
the  actual  state  of  the  lungs. 

Prognosis.- — ^\Tien  the  disease  is  present  at  birth  and  is  accompanied 
by  asphyxia  livida,  and  where  no  congenital  malformations  or  other 
pathological  conditions  are  present  the  prognosis  is  generally  favorable. 
When  atelectasis  occurs  in  premature  infants  the  result  is  more  uncertain 
on  account  on  the  constant  danger  of  relapse.  Yet  very  great  care  and 
watchfulness  will  often  succeed  in  saving  life. 

Diagnosis. — The  disease  is  to  be  distinguished  principally  from  the 
hypostatic  pneumonia  which  is  liable  to  develop  in  weakly  infants.  The 
absence  of  fever  and  of  bronchial  respiration  constitute  the  chief  diag- 
nostic evidences  against  pneumonia. 

Treatment. — Although  varying  with  the  nature  of  the  causes  and 
symptoms,  treatment  is  practically  identical  with  that  recommended 
for  asphyxia.  Cutaneous  stimulation,  artificial  respiration,  the  main- 
tenance of  the  bodily  temperature,  and  the  frequent  administration  of 
nourishment  are  indicated.  (See  Premature  Birth  and  Asphyxia,  pp.  252 
and  276.)  It  nuist  never  be  forgotten  that  atelectatic  infants  nuist  have 
an  abundance  of  fresh  warmed  air  and  must  not  be  allowed  to  lie  too 
long  in  one  position.  They  should  be  roused  from  their  somnolent 
condition  at  frequent  intervals  iwul  carried  about  cautiously;  and  be 
given  massage,  warm  baths  and  similar  measures  to  stimulate  both 
circulation  and  respiration. 


286  THE  DISEASES  OF  CHILDREN 

CHAPTER  IX 

CONGENITAL  ASTHENIA 

In  this  category  belong  the  infants  born  with  a  power  of  resistance 
to  deleterious  influences  and  a  capacity  of  thriving  under  ordinary  cir- 
cumstances much  below  normal.  The  condition  is  different  from  that 
of  premature  birth,  although  often  associated  with  it.  Premature 
birth  is  doubtless  the  most  frequent  cause,  but  not  every  case  of  pre- 
maturity exhibits  debility,  while,  on  the  other  hand,  infants  born 
at  full  term  may  be  suffering  from  asthenia.  Such  cases  of  congenital 
asthenia  may  be  the  result  of  prenatal  influences  such  as  prolonged 
illness  of  the  mother,  and  particularly  such  conditions  as  syphilis,  tuber- 
culosis, alcoholism,  and  the  like.  In  some  of  these  the  baby,  although 
born  at  term,  is  physically  premature,  the  maternal  condition  having 
interfered  with  intra-uterine  development.  In  other  cases  the  fact  that 
the  infant  is  one  of  multiple  births  accounts  for  the  asthenia.  The 
condition  is  much  the  same  whatever  the  cause,  and  the  symptoms  and 
treatment  are  fully  considered  in  the  chapter  on  Premature  Birth.  There 
is  often  a  difference,  however,  in  the  prognosis.  If  a  prematurely 
born  infant  with  asthenia  dependent  upon  no  maternal  disease  can  be 
maintained  alive  until  its  organs  reach  the  power  of  functionating 
properly,  the  prognosis  is  good;  whereas  the  infant  with  constitutional 
debility,  perhaps  depending  upon  prenatal  influences,  may  show  little 
increase  of  energy  as  time  passes. 


CHAPTER  X 
DISEASES  OF  THE  UMBILICUS 

Affections  of  the  navel  are  among  the  common  pathological  conditions 
of  the  new  born.  In  2G03  births  Porak  and  Durante^  found  some  ab- 
normality in  832  or  32.6  per  cent,  although  this  was  of  an  important 
nature  in  but  333;  viz.,  12.8  per  cent.  All  the  severer  forms  have  become 
much  less  frequent  since  antisepsis  has  been  practised  more  perfectly. 

The  various  umbilical  disorders,  with  the  exception  of  hernia  which 
will  be  discussed  later  (p.  790)  may  be  subdivided  as  follows: 

DELAYED  HEALING  OF  THE  UMBILICUS 
(Excoriation;  Blennorrhea;  Umbilical  Ulceration,  etc.) 

Under  this  title  Runge^  properly  groups  several  minor  affections  of 
the  umbilicus  which,  although  often  described  as  distinct  conditions,  are 
yet  clearly  allied. 

In  place  of  skinning  over  with  epithelium  a  few  days  after  the  fall  of 
the  cord,  the  umbilical  wound  sometimes  projects  slightly  and  becomes 
irritated  by  the  dressing  applied,  constituting  the  so-called  excoriatio 
umbilici.  If  a  flat,  red  surface  is  visible,  resembling  mucous  membrane, 
and  secreting  pus  more  or  less  abundantly,  blennorrhea  of  the  navel  is  spoken 

1  Arch,  de  m6d.  des  enf.,  1905,  VIII,  465. 

2  Krankh.  d.  ersten  Lebenstagen,  1893,  71. 


FUNGUS  OF  THE  UMBILICUS  287 

of.  Should  the  process  extend  in  area  or  in  depth  a  condition  of  genuine 
ulceration  is  produced  with  a  granulating  surface,  sometimes  covered 
with  necrotic  tissue  and  constituting  an  ulcus  umbilici.  This  ulcer  may 
develop  a  false  membrane,  and  is  then  entitled  croup  or  diphtheria  of  the 
navel,  without  the  process  necessarily  being  of  a  truly  diphtheritic  nature. 
Etiology. — The  causes  of  this  delayed  healing  are  various.  There 
is  a  certain  normal  variation  in  the  falling  of  the  cord  and  the  healing 
of  umbilical  wounds.  An  average  time  for  the  separation  of  the  cord  is 
the  5th  day,  and  for  the  healing  of  the  wound  the  12th  to  the  15th  day. 
In  strong  children  the  degree  of  inflammation  is  liable  to  be  more  intense 
than  in  weakly  ones,  the  cord  falls  sooner,  and  the  wound  heals  more 
rapidly.  It  is  only  when  the  inflammation  increases  after  the  cord  has 
separated  that  the  process  can  be  called  abnormal.  In  some  cases  local 
irritation  by  the  dressing  is  the  cause  of  the  inflammation.  Lack  of 
cleanhness  is  another  factor.  In  many  instances  a  local  infection  is 
without  doubt  present,  and  this  is  probably  nearly  always  the  case  when 
ulceration  develops.  It  is  also  likely  that  infection  has  taken  place 
if  decided  increase  of  redness  and  secretion  is  combined  with  a  much 
delayed  separation  of  the  cord. 

Symptoms. — No  general  symptoms  attend  these  different  forms  of 
delayed  healing  of  the  umbilical  wound,  and  no  danger  to  life  exists 
provided  they  remain  purely  local.  Even  ulceration  of  the  umbilicus  is 
without  involvement  of  the  general  health  unless  it  has  lasted  a  consider- 
able time.  Where  there  are  decided  constitutional  symptoms  accom- 
panying the  umbilical  lesions  described  infection  has  certainly  extended 
beyond  the  umbilicus. 

•  Treatment. — Inasmuch  as  the  persistence  of  the  umbiUcal  wound 
continues  the  liability  to  septic  infection,  treatment  is  necessary.  As 
a  prophylactic  measure  the  stump  of  the  cord  must  be  kept  as  dry  as 
possible  in  order  to  hasten  mummification  and  separation.  Should 
there  be  delay  in  healing  after  the  cord  has  separated,  dressings  with 
some  antiseptic  powder  are  to  be  preferred.  After  a  thorough  cleans- 
ing with  water  followed  by  careful  drying,  powdered  boric  acid  maj^  be 
applied  in  a  thick  layer,  or  a  mixture  of  salicylic  acid  and  starch  or 
talc  in  the  proportion  of  1:5,  and  this  covered  with  a  wad  of  absorbent 
cotton  and  a  bandage.  Washing  with  hydrogen  dioxide,  and  painting 
with  a  1  per  cent,  solution  of  nitrate  of  silver  arc  often  also  of  service. 
The  dry  dressing  should  be  renewed  once  or  twice  daily. 

FUNGUS  OF  THE  UMBILICUS 
(Granuloma;  Sarcomphalos ;  Umbilical  Polypus) 

After  the  separation  of  the  cord  an  abnormal  growth  sometimes 
develops  at  the  navel.  This  may  be  hidden  by  the  overlying  skin,  or 
may  project  as  a  round,  red  mass  the  size  of  a  pea  or  larger,  exhibiting  a 
granular  appearance  on  close  inspection.  The  surface  of  the  mass  is 
moist,  discharges  sero-purulent  fluid,  and  bleeds  slightly  when  irritated. 
Unless  treated  the  growth  may  persist  for  months.  The  general  health 
of  the  infant  is  unaffected. 

Anatomically  it  is  composed  of  granulation  tissue  which  has  developed 
upon  the  point  of  attachment  of  the  cord.  The  condition  can  always  be 
recognized  if  the  folds  of  the  skin  about  the  navel  arc  pulled  apart  in  a 
way  to  render  the  interior  visible.  It  is  to  l)e  distinguished  only  from  a 
persistent  Meckel's  diverticulum  (p.  810).     The  tendency  to  recovery 


288  THE  DISEASES  OF  CHILDREN 

unaided  is  slight,  and  the  umbiHcal  wound  cannot  heal  while  the  fungus 
is  present.  Treatment  consists  in  the  application  of  astringents,  pref- 
erabh^  nitrate  of  silver,  followed  by  a  dressing  of  powdered  boric  acid. 
This  may  be  repeated  every  few  days  if  necessary.  If  the  fungus  is  of 
considerable  size  it  may  be  ligated.  When  exuberant  granulations  have 
disappeared  an  antiseptic  dressing  may  be  applied  until  the  wound 
becomes  covered  with  epithelium. 

OMPHALITIS 
Periomphalitis 

Etiology. — The  term  is  used  to  designate  a  phlegmonous  inflamma- 
tion of  the  navel  and  surrounding  tissues.  It  is  not  of  frequent  occur- 
rence, Hennig^  finding  but  12  cases  among  7000  sick  infants.  The  cause 
is  a  pyogenic  infection,  to  which  uncleanliness  and  lack  of  proper  care  of 
the  navel  have  predisposed. 

Symptoms. — The  disease  begins  usually  in  the  2d  or  3d  week  of 
life,  after  separation  of  the  cord  and  as  a  sequel  to  a  delayed  healing  of 
the  umbilical  wound,  which  may  exhibit  ulceration  with  secretion  of 
pus.  The  skin  around  the  navel  is  swollen,  red,  hot,  shining  and  project- 
ing, with  a  disappearance  of  the  normal  folds.  The  subcutaneous  tissue 
is  infiltrated  and  hard,  and  the  slightest  pressure  causes  intense  pain. 
The  inflammation  may  remain  comparatively  superficial,  or  may  extend 
in  depth,  even  involving  the  peritoneum.  It  may  be  confined  to  the 
neighborhood  of  the  navel,  or  may  attack  the  greater  part  of  the  abdom- 
inal wall.  In  some  such  cases  it  is  very  probable  that  an  erysipelatous 
infection  has  been  added  to  the  omphalitis,  or  has  been  present  from  the 
beginning.  The  general  condition  of  the  infant  is  always  affected.  There 
is  restlessness,  loss  of  appetite,  and  fever.  Pain  is  a  prominent  feature, 
and  on  this  account  there  is  little  movement  of  the  abdomen  or  lower 
limbs,  the  thighs  are  generally  held  rigidly  flexed  on  the  abdomen,  res- 
piration is  superficial,  and  loud  crying  is  avoided.  The  emptying  of  the 
bladder  and  of  the  bowels  is  also  painful. 

Course  and  Prognosis.^ — The  duration  and  course  of  the  disease  is 
variable.  In  the  mild  cases  the  exudate  is  rapidly  absorbed.  A  few 
pustules  or  quite  small  abscesses  may  form  in  the  vicinity  and  recovery  is 
complete  in  a  few  days.  The  severe  cases  may  last  for  weeks,  the  infiltra- 
tion being  slowly  absorbed,  or  an  abscess  developing  and  discharging.  The 
prognosis  is  always  dubious.  Those  cases  generally  recover  in  which  the 
disease  spreads  but  little.  Where  the  process  is  intense  the  prognosis  is 
grave.  The  more  quickly  the  severer  cases  advance  to  the  formation  of 
abscess  the  better  for  the  child,  since  the  duration  of  the  inflammation 
and  the  consequent  exhaustion  are  thus  curtailed.  The  development  of 
a  complicating  gangrene  or  the  extension  of  the  lesion  to  the  peritoneum 
makes  the  prognosis  very  unfavorable.  If  the  inflammation  involves  the 
umbilical  vessels  general  septic  infection  will  probably  follow. 

Diagnosis.- — This  is  as  a  rule  rendered  evident  by  the  pain  and  the 
infiltrated,  hard,  prominent  umbilical  region.  The  formation  of  an 
abscess  is  shown  by  the  presence  of  fluctuation.  Erysipelas  is  generally 
distinguished  by  the  rapid  spreading  of  the  characteristic  color.  Yet 
when  erysipelas  exists  as  a  complication,  the  diagnosis  of  the  existence 
of  a  primary  omphalitis  becomes  most  difficult. 

1  Gerhardt's  Handb.  d.  Kinderkr.,  II,  131. 


GANGRENE  OF  THE  NAVEL  289 

Treatment. — This  is  first  of  all  prophylactic.  The  navel  must  be 
kept  aseptic  and  free  from  irritation.  If  omphalitis  has  already  com- 
menced, the  umbilical  wound  should  be  cleansed  carefully  and  then  pow- 
dered thickly  with  boric  acid,  iodoform,  salicylic  acid  and  starch  (1:  5), 
or  other  antiseptic  powder.  If  there  is  much  infiltration  of  the  tissues 
and  abdominal  pain,  the  inflamed  area  may  be  covered  with  a  warm, 
wet  antiseptic  dressing.  A  diluted  ichthyol  ointment,  5  to  10  per  cent, 
is  sometimes  useful.  Any  abscesses  which  form  should  be  incised  early. 
Attention  must  be  given  to  the  nourishment  of  the  infant,  forced  feeding 
being  used  if  necessary,  and  stimulants  being  required  in  many  cases. 
The  bowels  should  be  emptied  by  injections,  as  the  child  cannot  make 
any  effort  at  pressing. 

GANGRENE  OF  THE  NAVEL 

Etiology. — Gangrene  may  be  a  sequel  to  severe  cases  of  omphalitis, 
ulcer,  or  inflammation  of  the  umbilical  vessels.  It  is  now  very  rare  as  a 
purety  local  affection,  since  better  antiseptic  precautions  are  observed; 
but  is  still  seen,  though  infrequently,  as  a  secondary  manifestation  of  a 
general  septic  infection.  It  may  exceptionally  follow  severe  general 
diseases,  especially  diarrhea  of  a  choleraic  nature,  even  in  children  over 
a  month  old  and  previously  healthy.  The  existence  of  great  debility, 
as  in  cases  of  premature  birth,  favors  its  development.  An  especially 
potent  factor  is  lack  of  cleanliness  about  the  umbilical  wound. 

Pathological  Anatomy  and  Symptoms. — The  inflammation 
already  present  develops  into  a  greenish  or  black  offensive  mass  sur- 
rounded by  a  red  areola,  and  the  edges  of  the  wound  become  discolored 
and  break  down,  causing  a  more  or  less  rapid  loss  of  substance,  either  in 
area  or  in  depth.  In  the  latter  case  the  process  may  extend  to  the  peri- 
toneum, and  even  into  the  intestine,  producing  perforation  and  fecal 
fistula.  If  the  spreading  is  toward  the  periphery  the  greater  part  of 
the  superficial  abdominal  wall  may  be  destroyed,  involving  more  or  less 
the  muscular  layer  and  even  extending  to  the  bladder.  Severe  hemor- 
rhage may  occur  if  the  umbilical  vessels  are  involved.  General  sepsis 
may  be  produced  by  way  of  the  vessels  or  of  the  peritoneum.  The  con- 
stitutional symptoms  attending  gangrene  are  always  severe.  There  are 
great  prostration  with  coldness  of  the  extremities,  quick  and  weak  pulse, 
and  little  or  no  fever.  Rapid  collapse  is  frequent.  Occasionally  the 
process  is  not  so  serious,  the  gangrene  may  not  extend  far,  and,  the  reac- 
tive inflammation  producing  pus  the  dead  tissue  is  thrown  off  and  the 
cavity  fills  with  granulations.     The  diagnosis  offers  no  difficulty. 

Course  and  Prognosis. — The  duration  varies,  depending  upon  the 
resisting  power  of  th(>  infant  and  the  swiftness  of  the  spread  of  the  dis- 
ease. The  average  duration  of  fatal  cases,  according  to  Fiirth^  is  al)out 
K>\'2  days,  and  of  those  which  recover  about  22  days.  The  prognosis  is 
exceedingly  bad.  If  the  diseased  area  is  small,  the  infant's  strength 
good,  and  reactive  inflammation  soon  sets  in,  recovery  may  follow,  but 
the  mortality  reaches  over  85  per  cent.  (88.48  per  cent.,  Fiirth).  Absence 
of  the  surrounding  areola,  involvement  of  the  peritoneum,  severe  hem- 
orrhage from  the  umbilical  vessels,  and  develojiment  of  general  sepsis 
render  death  almost  inevitable,  (iangrenc  arising  as  an  affection  second- 
ary to  constitutional  conditions  and  other  diseases  is  uniformly  fatal. 

'  Wiener  Kliiiik,  1SS4,  X,  331. 
19 


290  THE  DISEASES  OF  CHILDREN 

Treatment. — This  consists  in  supporting  the  strength  by  means  of 
abundant  nourishment  and  powerful  stimulation,  the  maintaining  of  the 
temperature,  the  limiting  the  spread  of  the  disease,  and  the  favoring  of 
the  casting  off  of  the  dead  tissue  and  of  the  development  of  a  reactive 
inflammation.  Warm  wet  antiseptic  dressings  may  be  apphed.  The 
early  employment  of  the  thermo-cautery  may  be  efficacious.  After 
the  gangrenous  tissue  has  separated  iodoform  or  ichthyol  may  be  used. 

UMBILICAL  ARTERITIS  AND  PHLEBITIS 

Etiology. — Both  of  these  conditions  are  of  comparatively  unusual 
occurrence.  The  investigations  of  Runge^  show  that  inflammation  of 
the  arteries  is  far  more  common  than  that  of  the  vein.  In  55  cases  of 
disease  of  the  vessels  the  vein  was  found  affected  but  once  while  in  all 
instances  the  arteries  were  involved.  Of  all  affections  of  the  navel  arte- 
ritis appears  to  be  much  the  most  frequent  cause  of  death.  Phlebitis, 
too,  usually  leads  to  general  fatal  septic  inflammation.  The  cause  of 
disease  of  the  umbilical  vessels  is  always  an  infection  of  the  umbilical 
wound.  It  is  most  likely  to  occur  before  the  stump  of  the  cord  has  com- 
pletel}'  separated,  since  the  granulations  which  develop  later  form  to 
some  extent  a  protection  against  infection.  It  may  appear  as  an  epidemic 
in  lying-in  institutions,  although  this  has  become  very  much  less  frequent 
since  better  methods  have  prevailed.  The  infection  may  be  acquired 
from  the  lochial  discharges  of  the  mother,  or  be  transmitted  by  the  hands 
of  the  physician  or  nurse,  infected  umbilical  dressings,  or  even  appar- 
enth'  by  the  air  of  an  infected  room  or  the  water  used  for  bathing.  Any 
irritation  of  the  umbilical  wound  predisposes  to  it,  as  does  omphalitis 
or  gangrene  of  the  navel.  On  the  other  hand  the  vascular  infection  may 
occur  without  the  umbilical  wound  showing  anything  abnormal. 

Premature  infants  seem  especially  predisposed  to  the  disease.  The 
presence  of  moisture  and  decomposition  in  the  stump  of  the  umbilical 
cord  is  more  favorable  to  the  development  of  organisms  than  the  normal 
state  of  mummification  (Cholmorogoff).^  Various  organisms  have  been 
found  in  the  stump  of  the  cord  and  in  the  umbilical  wound  in  cases  of 
infection  of  the  vessels,  among  these  being  varieties  of  staphylococci,  the 
streptococcus  pyogenes,  the  bacillus  coh,  the  pneumococcus,  and  the 
bacillus  pyocyaneus. 

Pathological  Anatomy. — The  process  always  begins  as  an  infec- 
tion and  inflammation  of  the  perivascular  tissue,  according  to  the  state- 
ments of  Runge,^  which  becomes  infiltrated  and  swollen.  It  next  ex- 
tends to  the  vessel-walls  and  a  septic  thrombus  forms  in  the  vessel. 
The  disease  usually  remains  local,  resulting  in  suppuration  in  or  about 
the  affected  portion  of  the  vessel  or  between  the  abdominal  wall  and  the 
peritoneum,  and  the  final  discharge  of  pus.  In  a  smaller  number  of 
cases  the  process  spreads  by  continuity  along  the  perivascular  tissues, 
the  sepsis  reaching  the  general  system  through  the  perivascular  lymph 
channels. 

On  inspection  at  autopsy  the  diseased  arteries  are  visible  as  thickened, 
stiff  and  discolored  cords,  surrounded  by  edematous  infiltrated  con- 
nective tissue.  The  vessels  of  the  adventitia  are  abundant.  Nearly 
always  both  arteries  are  involved  either  for  a  short  distance  only  or 

1  Krankh.  d.  ersten  Lebenstagen,  1893,  88. 

2  Zeitsch.  f.  Geburtsh.  u.  Gynak.,  1889,  XVI,  16. 
^  Loc.  cit. 


I 


UMBILICAL  ARTERITIS  AND  PHLEBITIS  291 

throughout  their  extent.  They  contain  broken-down  thrombi,  partially 
greenish  in  color  from  the  purulent  changes,  partially  still  bloody.  The 
intima  of  the  vessel  is  without  the  natural  shining  character  and  exhibits 
loss  of  endothelium.  The  lesions  of  the  umbilical  vein  are  identical  with 
those  of  the  arteries,  and  the  process  usually  extends  throughout  its 
entire  length  up  to  the  liver  and  even  into  it.  The  umbilical  wound  may 
appear  perfecth'  normal  or  may  exhibit  the  lesions  of  ulcer  or  of  ompha- 
litis. Even  if  the  stump  of  the  cord  is  mummified  and  still  persists, 
foci  of  suppuration  ma}'  be  discovered  about  the  periphery  of  the  region 
of  beginning  detachment.  Some  of  the  lesions  of  a  general  septic  infec- 
tion may  be  present,  such  as  have  been  described  in  considering  Sepsis 
in  the  New  Born.  (See  p.  258.)  In  the  case  of  phlebitis  the  liver  may  be 
involved  directlj^  b}'  continuity  from  the  umbilical  vein. 

Symptoms  and  Diagnosis. — Characteristic  symptoms  of  the 
disease,  apart  from  the  pathological  lesions,  are  practically  absent. 
When  the  process  remains  a  local  one,  as  is  true  of  the  majority  of  cases, 
the  symptoms  are  chiefly  local.  If  the  portion  of  the  vessel  immediately 
beneath  the  navel  is  involved,  crusts  may  appear  upon  the  umbilical 
wound,  or  there  may  be  discharged  from  it  on  pressure  pus  which  clearly 
comes  from  beneath  the  surface.  In  the  cases  where  a  portion  of  the 
vessel  more  deeply  situated  is  the  seat  of  the  lesion,  the  navel  is  of  normal 
appearance.  In  some  such  instances  the  hard  and  thick  arteries  can  be 
felt  through  the  abdominal  wall.  Sometimes  abscess  forms  above  the 
peritoneum  and  may  make  its  way  in  different  directions.  Moderate  fever 
and  other  constitutional  disturbances  may  be  present,  but  frequently 
no  general  symptoms  whatever  are  discovered;  and  it  may  well  be  that 
death  occurs  unexpectedly,  and  only  at  autopsy  is  an  umbilical  arteritis 
found.  In  the  more  severe  cases,  in  many  of  w'hich  the  vessels  are 
involved  throughout  much  of  their  extent  and  general  sepsis  follows, 
there  is  often  no  disorder  of  the  navel  visible,  the  symptoms  are  very 
uncharacteristic,  and  there  are  no  positive  means  of  recognizing  the 
disease  during  life.  Without  any  apparent  reason,  or  with  no  previous 
evidence  of  illness,  the  infant  becomes  restless,  loses  appetite,  develops 
irregular  and  often  high  fever,  and  passes  rapidly  into  collapse.  Less 
frequently  the  duration  is  more  prolonged,  and  symptoms  of  grave 
constitutional  disturbance  are  present.  High  fever  and  collapse  alternate, 
and  wasting  becomes  great.  There  is  diarrhea  and  distended  and  tender 
abdomen.  Intense  icterus  is  constantly  present  in  umbilical  phlebitis  if  the 
condition  is  at  all  prolonged  (Wiederhofer),^  and  is  frequent  in  arteritis 
also.  In  neither  case  is  there  any  reason  to  justify  the  diagnosis  of  ex- 
tensive inflammation  of  the  umbilical  vessels  unless  the  umbilical  wound 
is  distinctly  diseased,  in  which  event  the  suspicion  is  warrantable,  al- 
though proof  is  absent.  When  evidences  of  diffuse  general  pyemia  de- 
velop, the  diagnosis  of  an  umbilical  arteritis  or  phlebitis  is  rendered  still 
more  probable,  although  not  even  then  certain. 

Complications. — Pneumonia  is  that  oftenest  seen,  and  may  be 
the  only  one.  It  occurred  in  22  of  Runge's  55  cases.  All  the  widespread 
local  pyemic  lesions  of  sejitic  infection  may  occur  as  complications, 
among  these  empj^ema,  peritonitis,  suljcutaneous  abscess,  nephritis,  and 
the  like.  (See  Septic  Infection  of  the  Newborn,  p.  258.)  Erysipelas 
may  sometimes  develop  as  a  complication. 

Course  and  Prognosis. — As  we  cannot  discover  the  time  when  the 
disease  begins  the  exact  duration  is  uncertain.     In  nearly  all  instances 

1  Jahrb.  f.  Kiiideilioilk.,  lS(i2.  V,  195. 


292  THE  DISEASES  OF  CHILDREN 

it  is  short,  ranging  from  a  few  days  to  several  weeks.  The  greater  number 
of  deaths  in  Runge's  cases  occm-red  on  the  8th  day  of  Ufe.  The  progno- 
sis is  always  grave.  Since  the  diagnosis  can  only  he  made  with  certainty 
at  the  autopsy,  it  is  impossible  to  determine  its  fatality,  but  it  is  probable 
that  recovery  does  occur  in  many  instances  if  the  process  does  not  spread 
beyond  the  vessels.  Should  the  sepsis  become  general  death  is  almost 
inevitable. 

Treatment. — Prophylaxis  is  the  most  important.  Careful  antiseptic 
treatment  of  the  umbilicus  is  necessary  from  the  moment  of  birth.  The 
hands  of  the  phj^sician  and  nurse  must  be  aseptic,  the  scissors,  ligature 
and  dressings  likewise  so,  and  precautions  taken  at  all  times  against 
the  access  of  germs.  The  child  should  be  at  once  removed  from  the 
vicinity  of  the  mother  if  she  has  any  evidence  of  sepsis.  The  stump  of 
the  cord  must  be  kept  as  dry  as  possible  in  order  to  avoid  a  moist  decom- 
position, and  the  frequent  renewal  of  antiseptic  dressings  may  be  neces- 
sary to  accomplish  this.  The  use  of  salicylated  cotton  with  a  powder  of 
salicylic  acid  and  talcum  (1  :5)  is  useful  for  this  purpose.  The  employ- 
ment of  powdered  gypsum  on  cotton  has  been  recommended  by  Sutu- 
gin,^  Cholmogoroff^  and  others  as  the  best  means  of  accomplishing  this. 
Such  a  dressing  should  be  used  as  will  not  shut  out  air  too  greatly,  since' 
rapid  drying  is  hindered  in  this  way.  When  the  cord  has  separated  the 
wound  should  be  dressed  with  the  powder  of  salicylic  acid  and  talcum,  or 
one  of  salicylic  acid  and  starch,  (1  :5)  or  with  boric  acid  or  iodoform. 
If  the  navel  is  already  diseased  in  anj^  way  the  treatment  indicated  for 
the  condition  present  must  be  employed  in  order  to  prevent  the  spread  of 
infection  to  the  vessels. 

Treatment  of  the  disease  itself  is  rarely  possible  even  could  the  diag- 
nosis be  made  with  certainty.  The  preservation  of  the  strength  by 
abundant  nourishment  and  by  the  free  use  of  stimulants  is  indicated. 
Complications  are  to  be  treated  as  they  arise. 

OMPHALORRHAGIA 

(Umbilical  Hemorrhage)  « 

(See  also  Hemorrhage  in  the  New  Born,  p.  263) 
This,  like  melena,  is  not  a  distinct  disease,  but  a  symptom  of  different 
conditions,  itself  of  enough  importance  to  warrant  separate  considera- 
tion. It  is  customary  to  recognize  2  forms  (A)  accidental,  proceeding 
from  the  umbilical  vessels,  and  (B)  idiopathic  or  spontaneous  coming  from 
the  umbilical  tissues. 

Etiology. — (A)  Accidental  Hemorrhage. — Severe  hemorrhage  from 
the  umbilical  vessels  may  occur  before  the  fall  of  the  cord  as  a  result  of 
imperfect  ligation  of  it.  The  ligature  may  have  been  too  loose,  or  may 
have  slipped,  or  have  cut  into  the  vessels.  Under  otherwise  normal  con- 
ditions hemorrhage  from  such  causes  will  not  take  place  except  in  the 
first  10  or  15  minutes  of  life.  When,  however,  under  the  influence  of 
well-developed  asphyxia  in  otherwise  healthy  infants,  or  especially  in  the 
slow,  unsatisfactory  expansion  of  the  lungs  in  premature  infants,  the  blood 
is  not  drawn  into  the  expanding  lungs  in  a  normal  manner,  there  results 
a  maintenance  of  the  blood-pressure  in  the  umbilical  arteries,  the  muscle 
of  the  arterial  walls  fails  to  contract  and  close  the  lumen  properly,  and 

1  Wratsch,  1883,  No.  44,  Ref. 

2  Loc.  cit.,  28. 


OMPHALORRHAGIA  293 

the  occurrence  of  hemorrhage  is  possible.  In  like  manner  gangrene  of 
the  umbilicus  or  imperfect  mummification  allows  the  vessels  to  open 
again  and  blood  to  escape.  It  is  possible,  too,  that  a  bath  too  prolonged 
and  too  hot  may  relax  the  vessels  and  permit  of  hemorrhage.  Hemor- 
rhage very  rarely  results  from  rupture  of  the  cord  during  birth  in  the 
case  of  healthy  children. 

After  the  separation  of  the  cord  a  slight  oozing  from  the  umbilical 
vessels  is  not  uncommon.  This  occurs  of  tenest  when  the  umbilical  wound 
is  healing  slowly  or  has  been  roughly  handled.  Rarely  the  bleeding  is 
severe. 

(B)  Idiopathic  Hemorrhage. — Bleeding  of  this  variety  from  the 
umbilical  wound,  decidedly  more  common  than  from  the  vessels,  is  a  very 
dangerous  affection,  the  causes  of  which  are  diverse  and  little  understood. 
Grandidier^  writing  in  1871  collected  220  cases  from  medical  literature. 
Townsend^  reported  14  cases  in  7225  births.  Winckel^  observed  it  in 
only  1  of  5000  births.  The  condition  would  appear  perhaps  to  be  more 
frequent  than  these  statistics  indicate,  inasmuch  as  many  cases  are  never 
reported.  It  occurs  oftenest  after  the  complete  separation  of  the  stump 
of  the  cord.  ^Vlales  exhibit  it  oftener  than  females.  The  general  con- 
dition of  the  infant  is  of  doubtful  influence.  It  is  possible  that  poor 
health  of  the  mother  during  pregnancy  may  predispose  to  the  develop- 
ment of  the  disease,  but  this,  too,  is  doubtful.  Certainly  congenital 
syphilis  appears  to  be  a  prominent  cause  of  umbilical  as  of  other  forms 
of  hemorrhage  in  the  new  born.  Septic  disease  of  the  new  born  also  pro- 
duces it.  (See  p.  258.)  Epstein^  found  well-marked  sepsis  in  24  out  of 
51  fatal  cases  of  hemorrhage.  The  presence  of  microorganisms  plays 
an  important  part  in  the  causation  of  many  cases.  Among  those  found 
in  the  blood  or  at  autopsy  are  the  streptococcus  pyogenes,  pneumococcus, 
staphylococcus  pyogenes,  bacillus  pyocyaneus,  colon  bacillus,  and  others 
(Abt).^  Numerous  cases,  however,  have  shown  no  evidence  whatever  of 
sepsis.  Umbilical  hemorrhage  is  one  of  the  symptoms  of  acute  fatty 
degeneration,  and  especially  of  the  hemorrhagic  disease  of  the  new  born 
previously  referred  to  (p.  264).  The  influence  of  hemophilia  is  negligible, 
since  this  disease  rarely  shows  itself  until  later  in  life.  Larrabee*^  was  able 
to  collect  but  23  cases  from  medical  literature  in  which  umbilical  hemor- 
rhage could  be  considered  as  dependent  upon  hemophilia. 

Symptoms. — Severe  accidental  hemorrhage  is  usually  sudden  and 
profuse,  and  may  terminate  life  quickly  unless  checked  at  once.  The 
blood  can  often  be  seen  flowing  directly  from  an  open  vessel.  It  occurs 
generally  a  few  minutes  after  birth,  or,  in  the  case  of  premature  infants 
with  evidences  of  asphyxia,  during  the  first  few  hours  of  life,  or  occasion- 
ally later;  sometimes  even  after  the  cord  has  fallen.  After  the  separa- 
tion of  the  cord  the  hemorrhage  is  usually  in  the  form  of  oozing  only. 
This,  too,  can  often  be  seen  to  come  from  a  vessel. 

No  general  symptoms  attend  the  accidental  hemorrhage  other  than 
those   of   anemia,    nor   is  there  Ijlccding  from  other  parts  of  the  body. 

Idiopathic  hemorrhage  usually  occurs  somewhere  between  the  5th 
and  the  10th  days  of  life,  although  it  may  occur  earlier  or  later  than  this. 

^  Die  froiwillige  Xabolblutung  d.  Neugeb.,  1871.  Rcf.  Runge,  Die  Ivraiikh.  dtT 
orsten  Ijebenstagen,  1906,  224. 

=  Boston  Mod.  and  Surg.  .Journ.,   1891,  CXXV,  218. 
'Lehrb.  d.   Gchurtsh.,   189:3,   854. 

*  Oester.  Jahrb.  f.   Piidiat.,  lS7(i,  VII,  1.39. 

'Journ.  Amer.  Med.  Assoc,  1903,  XIj,  284,  for  literature. 

•  Amer.  Journ.  Med.  .Sei.,   1900,   March. 


294  THE  DISEASES  OF  CHILDREN 

It  is  very  frequently  combined  with  the  occurrence  of  bleeding  in  other 
parts  of  the  bod}'.  Beginning  slowly  it  becomes  fairly  free  and  saturates 
the  dressing,  j'et  it  appears  to  be  capillary  in  origin.  Sometimes  it  is 
profuse  from  the  start.  A  characteristic  of  the  disease  is  that  effort  to 
check  the  bleeding  has  but  a  temporary  effect,  if  any.  Very  occasionally 
the  hemorrhage  stops  of  itself  for  a  time  and  then  is  renewed.  The  blood 
has  little  tendency  to  coagulate,  but  microscopic  examination  shows 
nothing  abnormal  in  it.  The  infants  may  appear  at  first  perfectly  healthy 
in  every  other  respect,  or  may  have  seemed  not  quite  well  before  the 
hemorrhage  began,  or  have  looked  ill  and  been  somnolent  or  cyanotic  or 
exhibited  diarrhea,  vomiting  or  decided  icterus.  In  all  cases  decided 
evidence  of  general  disturbance  appears  sooner  or  later,  apart  from  the 
results  of  the  loss  of  blood.  Icterus  often  becomes  intense;  cyanosis  may 
develop,  if  not  earlier  present;  and  hemorrhage  from  other  parts  of  the 
body  often  appears,  or  in  other  instances  may  have  antedated  the  um- 
bilical hemorrhage.  Not  infrequently  bleeding  takes  place  not  only  from 
the  navel,  but  into  the  subcutaneous  tissues  about  it.  Edema  of  the 
wrists  and  ankles  is  common.  As  the  hemorrhage  continues  anemia 
becomes  profound,  and  death  occurs,  sometimes  preceded  by  coma  or 
convulsions. 

Prognosis. — The  prognosis  in  accidental  hemorrhage  is  favorable 
if  the  bleeding  is  not  too  profuse  at  the  beginning  and  is  discovered  and 
checked  at  once.  In  idiopathic  hemorrhage  it  is  unfavorable.  Sta- 
tistics give  from  25  to  35  per  cent,  of  recoveries  only.  When  the  disease 
depends  on  sepsis,  acute  fatty  degeneration,  or  syphilis,  practically 
no  hope  of  recovery  exists.  Death  may  occur  in  less  than  24  hours 
and  the  average  duration  of  life  from  the  onset  in  fatal  cases  is  only 
2  to  3  days,  and  is  seldom  longer  than  2  weeks. 

Diagnosis. — The  distinction  is  to  be  made  only  between  the  two 
varieties  of  umbilical  hemorrhage.  Careful  inspection  and  the  course 
of  the  case  will  generally  make  the  matter  clear. 

Treatment. — Prophylactic  treatment  for  accidental  hemorrhage 
consists  in  the  proper  ligation  of  the  umbilical  cord  not  too  close  to  the 
body  (see  page  168),  in  gentle  handling  of  it  afterward  and  in  care 
in  the  removing  of  all  evidences  of  asphyxia  as  soon  as  possible.  Should 
hemorrhage  occur  a  new  ligature  must  be  tied  at  once.  If  there  is  no 
room  to  apply  this,  or  if  there  is  free  hemorrhage  after  the  separation 
of  the  cord  it  may  be  necessary  to  apply  a  compress  or  even  to  push  two 
needles  through  the  skin,  above  and  below  the  seat  of  bleeding,  and  ligate 
around  these.  If  the  bleeding  is  very  slight  the  application  of  an  astrin- 
gent powder  or  the  use  of  compresses  moistened  with  tr.  ferri  chloridi 
or  liquor  ferri  subsulphati  may  suffice.  For  the  anemia  which  may 
have  developed  are  to  be  employed  free  stimulation,  abundant  nourish- 
ment, the  maintaining  of  the  heat  of  the  body,  and  later,  measures  to 
aid  the  enriching  of  the  blood. 

In  the  case  of  idiopathic  hemorrhage  prophylaxis  consists,  first, 
in  attending  carefully  to  the  general  health  of  the  mother  before  the 
birth  of  the  child  and  in  giving  to  her  the  treatment  indicated  if  there 
are  any  evidences  of  syphilis.  Great  care  must  be  taken  after  the  birth 
of  the  infant  to  guard  against  septic  infection  from  any  source.  If 
hemorrhage  begins  styptic  applications  may  be  tried,  such  as  alum  or 
tannic  acid,  and  especially  the  use  of  firm  compresses  moistened  with 
tincture  of  the  chloride  of  iron.  These  may  be  fastened  in  place  with 
broad  bands  of  adhesive  plaster  crossing  over  the  navel  and  drawn  firmly, 


MASTITIS  295 

finishing  on  the  back.  It  has  also  been  recommended  to  pour  moistened 
plaster  of  Paris  on  the  navel  and  allow  it  to  remain  for  several  days.  Acu- 
puncture with  the  application  of  a  ligature  about  the  needles  may  be 
employed  in  the  manner  already  described. 

The  administration  of  a  5  per  cent,  solution  of  gelatine  freely  by  enema 
or  by  the  mouth  is  worth}^  of  trial.  Still  better  is  its  subcutaneous 
use  after  very  carefully  repeated  sterilization  (p.  232). 

Against  the  anemia  the  measures  already  mentioned  are  indicated. 

PROTRUDING  MECKEL'S  DIVERTICULUM 

(See  also  Diseases  of  Meckel's  Diverticulum,  p.  809) 

py  This  rare  affection  at  first  sight  resembles  the  Fungus  of  the  Umbilicus 
(p.  287).  It  consists  of  a  prolapse  at  the  navel  of  the  terminal  portion 
of  the  omphalomesenteric  duct  which  has  failed  to  close  and  to  disappear 
early  in  fetal  life.  It  is  generally  patulous  throughout,  forming  a 
fistulous  tract  from  the  umbilicus  to  the  small  intestine.  In  appearance 
it  is  usually  a  reddish  tum^r  of  glistening  surface,  moist  with  mucous 
secretion.  Microscopical  examination  shows  that  it  is  of  the  same 
structure  as  the  intestinal  wall  and  that  the  surface  is  composed  of  mucous 
membrane.  It  is  generally  of  the  size  of  a  pea  or  bean,  although  some- 
times much  larger,  and  shows  a  central  opening  through  which  a  small 
amount  of  fecal  matter  may  be  discharged  from  time  to  time.  This 
condition  may  last  for  years,  or  the  duct  may  close  spontaneouslj\ 
In  some  cases  the  fistula  is  much  larger,  and  the  posterior  wall  of  the  in- 
testine, and  finally  even  quite  a  large  portion  of  the  bowel  may  project 
through  it  in  the  form  of  two  intussusceptions  each  with  its  central 
opening. 

The  treatment  of  the  protruding  diverticulum,  if  small,  consists  in 
the  application  of  a  ligature.  The  larger  protrusions  are  more  difficult 
of  cure  and  the  prognosis  is  unfavorable. 


CHAPTER  XII 
MASTITIS 


The  activity  of  the  mammary  glands  so  frequently  present  in  the 
new  born  (see  p.  60),  producing  enlargement  with  secretion  of  fluid, 
may  pass  into  an  actual  inflammatory  condition,  and  is  then  known  as 
mastitis. 

Etiology. — The  condition  is  not  an  uncommon  one,  and  either  sex 
may  be  attacked.  As  a  rule  it  occurs  only  in  a  breast  in  which  secretion 
has  been  free  and  has  continued  for  some  time.  Sometimes  an  ignorant 
mother  or  nurse  is  led  to  squeeze  or  rub  such  a  breast  repeatedly,  with  the 
idea  that  it  is  necessary  or  that  the  manipulation  favors  a  good  develop- 
ment of  the  gland  later  in  life.  The  irritation  produced,  combined  with 
want  of  cleanliness,  favors  the  entrance  of  germs  through  the  ducts 
or  through  fissures  and  suppuration  follows. 

Symptoms.^ — ]\Iastitis  begins  usually  in  the  2d  or  3d  week  of  life, 
but  may  occur  later  in  infancy.  The  breast,  generally  only  one,  grows 
uniformly  larger,  red,  hot,  and  painful  on  pressure  (Fig.  49).     As  a  rule 


296 


THE  DISEASES  OF  CHILDREN 


suitable  treatment  emploj^ed  at  this  period  prevents  the  disease  from 
advancing  farther,  and  the  inflammation  subsides  in  a  few  days.  In 
many  cases,  however,  particularly  if  the  squeezing  of  the  breast  is  still 
continued,  suppuration  takes  place  and  a  circumscribed  abscess  forms. 
Less  frequently  there  are  multiple  abscesses.  Fever,  restlessness,  loss 
of  appetite,  sleeplessness,  and  loss  of  weight  attend  the  suppurative 
process.  Occasionally  the  inflammation  spreads  beyond  the  gland  to 
the  surrounding  connective  tissue,  and  in  rare  instances  this  peri- 
mastitis may  involve  much  of  the  anterior  and  lateral  walls  of  the  thorax. 


Fig.  49. — Mastitis. 
Male  infant,  aged  25  days. 

Prognosis. — The  prognosis  of  mastitis  of  the  new  born  is  nearly 
always  good.  Even  in  the  cases  where  abscess  forms  recovery  follows 
unless  suppuration  is  very  extensive.  Yet  permanent  injury  may  easily 
remain,  the  secreting  power  of  the  gland  in  later  life  in  females  being 
destroyed  or  impaired,  or  the  nipple  being  retracted  or  otherwise 
distorted. 

Treatment. — The  disease  should  be  prevented  by  careful  pro- 
phylactic measures.  All  pressure  or  rubbing  of  the  breast  of  the  new 
born  is  to  be  avoided,  and  cleanliness  is  to  be  enforced.  If  the  gland  is 
more  swollen  than  common  and  inflammation  is  feared,  a  wad  of  aseptic 
absorbent  cotton  may  be  laid  over  it  to  protect  from  pressure  and  to 
prevent  infection.  If  mastitis  actually  begins,  hot,  wet  applications  may 
be  employed.  Any  abscess  forming  should  be  opened  promptly  and 
freely,  and  the  infant  given  tonic  treatment. 


CHAPTER  XIII 
OPHTHALMIA  NEONATORUM 

Although  occurring  later  in  life  as  well,  this  form  of  ophthalmia  is  so 
much  more  prevalent  in  the  new  born  that  it  may  properly  be  described 
in  connection  with  the  diseases  of  this  period  of  life.  The  affection  is  still 
a  common  one,  although  less  so  than  formerly.  This  is  particularly  true 
of  lying-in  institutions,  where  in  earlier  times  it  often  prevailed  epidemic- 
ally, from  5  per  cent,  to  even  20  per  cent,  of  the  children  born  being 
affected  by  it.     The  improvement  in  the  statistics  is  shown  by  those  of 


OPHTHALMIA  NEONATORUM  297 

Harman^  who  found  that  it  occurred  in  but  0.843  per  cent,  of  all  births 
in  London  in  1911.  The  greater  sensitiveness  of  the  conjunctiva  in  the 
new  born  certainly  predisposes  to  the  disease. 

Etiology. — Infection  is  the  cause  in  all  instances.  This  is  generally 
acquired  from  the  vaginal  discharges  at  the  time  of  birth,  while  the  head 
is  passing  through  the  genital  canal  of  the  mother.  In  other  cases  the 
infection  comes  from  the  fingers  of  the  physician,  mother,  or  nurse,  or 
from  infected  clothing.  It  is  also  possible  for  the  infectious  matter  to 
penetrate  beneath  the  lids  even  before  birth  after  the  amniotic  sac  has 
ruptured.  Although  such  germs  as  the  colon  bacillus,  pneumococcus  and 
others  are  capable  of  producing  the  disease,  yet  in  the  great  majority  of 
cases,  especially  if  severe,  the  gonococcus  is  the  cause.  The  milder  cases 
may  owe  their  origin  to  exposure  to  too  bright  a  light,  trauma,  and  the 
like,  which  allows  a  mild  non-gonorrheal  infection  to  take  place. 

Symptoms.- — The  process  may  affect  both  eyes  simultaneously,  or 
may  spread  from  one  eye  to  the  other.  Only  exceptionally  is  but  one  eye 
involved.  In  the  cases  of  a  catarrhal,  non-specific  nature  the  symptoms 
are  generally  mild.  They  then  consist  of  photophobia,  redness  of  the 
palpebral  conjunctiva,  and  slight  serous  secretion  which  collects  in  the 
corners  or  on  the  edges  of  the  lids.  The  course  is  short,  and  the  inflamma- 
tion has  generally  disappeared  in  a  few  days. 

In  the  gonorrheal  cases  the  symptoms  usually  appear  on  the  3d  or 
4th  day  after  birth  or  occasionally  earlier.  The  first  evidences  are 
swelling  and  redness  of  the  palpebral  and  injection  of  the  bulbar  conjunc- 
tiva, while  a  slight  watery  discharge  is  seen  on  separating  the  lids.  The 
course  of  the  disease  is  violent  and  rapid.  In  a  few  hours  the  lids  be- 
come red,  hot,  stiff  and  extremely  swollen,  closing  the  eye  tightly  and  being 
separated  with  difficulty  by  the  fingers;  the  conjunctiva  becomes  much 
swollen  with  an  abundant  infiltration  of  lymphoid  cells  and  gonococci; 
the  secretion  is  somewhat  more  abundant  and  of  a  more  purulent  charac- 
ter; the  cornea  becomes  involved,  and  in  bad  cases  is  liable  to  ulcerate, 
and  perforation  of  it  may  occur  even  during  the  2d  day.  In  a  few  days 
the  swelling  of  the  lids  diminishes,  but  the  redness  of  the  conjunctiva 
does  not  lessen,  and,  in  cases  which  have  not  been  benefited  by  treat- 
ment, folds  and  roughnesses  develop  on  it  giving  the  appearance  of 
granulation  tissue,  while  the  secretion  becomes  still  more  abundant  and 
quite  purulent.  General  symptoms  are  absent  or  shght,  although  con- 
siderable fever  may  be  present  in  the  severer  cases.  Recovery  takes  place 
slowly.  The  duration  is  variable,  the  average  being  3  to  5  weeks.  The 
severe  cases  run  6  to  8  weeks  if  not  influenced  by  treatment. 

In  cases  where  the  cornea  is  involved  this  becomes  cloudy,  opaque  and 
dull  in  appearance,  and,  if  ulceration  occurs  and  is  followed  by  perfora- 
tion, the  aqueous  humor  is  discharged  and  the  iris  may  prolapse.  Total 
blindness  is  liable  to  result,  or  the  whole  eye  may  be  destroyed  by  a 
panophthalmitis.  If  the  ulcer  does  not  perforate  healing  gradually 
takes  place  and  a  localized  opacity  develops  which  gradually  becomes 
more  transparent.  Where  treatment  has  been  successful  the  severity 
and  duration  of  the  inflammatory  process  are  materially  lessened. 

Complications. — Chief  among  the  complications  is  the  occasional 
development  of  gonorrheal  arthritis.  This  has  been  recorded  repeatedly. 
Secondary  gonorrheal  infection  of  the  nose  or  mouth  has  been  occasionally 
recorded. 

^Lrit.  Med.  Journ.,  H)i;^,  I,  1035). 


298  THE  DISEASES  OF  CHILDREN 

Prognosis. — The  prognosis  of  the  severe  form  of  inflammation  is 
extremel}^  grave  as  regards  loss  of  vision  in  cases  which  have  not  received 
prompt  and  efficient  treatment.  Formerly  a  large  number  of  cases  of 
blindness  were  due  to  this  disease.  The  statistics  of  Reinhardt^  concern- 
ing the  inmates  of  the  blind  asylums  of  Germany,  Austria,  Denmark  and 
Holland  combined  covering  the  years  1865-1875,  showed  that  40.25  per 
cent,  had  lost  their  sight  through  ophthalmia  neonatorum.  Prompt  and 
thorough  treatment  reduces  the  danger  greatly,  especially  in  the  new 
born.  If  involvement  of  the  cornea  has  already  commenced  before 
treatment  is  begun  the  prognosis  is  graver. 

Diagnosis. — The  diagnosis  of  the  gonorrheal  form  is  based  upon  the 
rapid  and  great  swelling  of  the  lids  and  other  evidences  of  very  severe 
inflammation  of  the  eye,  and  later  upon  the  free  secretion  of  pus  and  the 
discovery  of  the  gonococcus.  Diphtheritic  conjunctivitis  occurs  verj'- 
rarely  in  infants  and  can  be  distinguished  by  the  presence  of  a  false 
membrane  and  of  the  characteristic  bacilli,  as  well  as  by  the  lesser  degree 
of  swelling  and  the  absence  of  the  granulation-like  appearance  of  the 
lining  of  the  lids. 

Treatment.^ — Chief  in  the  line  of  treatment  is  careful  prophylaxis. 
The  frequency  of  the  disease  in  institutions  has  been  decidedly  lessened 
since  Crede^  urged  the  dropping  of  a  2  per  cent,  solution  of  nitrate  of 
silver  into  the  eyes  of  every  child  immediately  after  birth.  Of  1160 
infants  treated  in  this  manner  in  the  Leipzig  Obstetrical  Clinic  only  1 
or  possibly  2  developed  ophthalmia;  i.e.  0.086  to  0.172  per  cent.;  whereas 
earlier  statistics  based  on  4057  infants  in  the  same  maternity  had  given 
7.8  per  cent,  suft'ering  from  ophthalmia.  Observations  of  most  later 
investigators  are  in  entire  accord  with  the  results  obtained  by  Crede.  The 
use  of  an  antiseptic  vaginal  injection  before  labor  is  also  to  be  recom- 
mended. In  private  practice  the  instillation  and  the  vaginal  douching 
should  be  employed  if  there  exists  any  probability  that  the  vaginal  secre- 
tion of  the  mother  may  be  gonorrheal  in  nature.  Newer  silver  compounds 
have  been  recommended  to  replace  the  nitrate  solution.  Thus  a  solution 
of  protargol  (5  to  20  per  cent.)  or  of  argyrol  (25  per  cent.)  has  been 
employed  with  success  instead  of  that  of  nitrate  of  silver,  but  would  appear 
to  be  less  certain  in  its  results.  The  water  in  which  the  child  is  bathed 
must  never  be  used  for  the  washing  of  the  eyes.  In  cases  where  the 
danger  of  gonorrheal  infection  is  entirely  unlikely  the  eyes  should  be 
thoroughly  cleansed  after  birth  with  cotton  moistened  with  distilled  water 
or  a  saturated  solution  of  boric  acid.  To  prevent  the  milder  form  of  con- 
junctival inflammation  the  eyes  of  the  new-born  infant  must  be  protected 
from  too  bright  a  light  and  from  mechanical  injury. 

When  gonorrheal  ophthalmia  develops  in  an  infant  in  a  maternity  or 
a  hospital  ward  the  patient  should  at  once  be  isolated,  and  the  nurse  in 
charge  should  have  nothing  to  do  with  the  other  children.  In  all  cases 
of  the  disease  the  cloths,  cotton,  and  the  like  used  about  the  eyes  should 
be  promptly  destroyed.  The  sound  eye,  if  one  only  is  affected,  must  be 
carefully  protected  by  covering  it  with  a  wad  of  antiseptic  cotton  and 
enveloping  with  a  gauze  bandage.  The  hands  of  the  child  must  also  in 
manj^  cases  be  restrained  by  bandaging  them  to  the  sides  or  in  other 
ways.     The  two  chief  indications  in  treatment  are  the  repeated  thorough 

"^ Zweiter  europ.  Blindenlehrer-Congr.,  Dresden,  1876  Ref.  Magnus;  Die  Blindheit, 
1883,  165. 

2  Arch.  f.  Gyn.,  1881,  XVII,  50;  188.3,  XXI,  179.  Die  Verhutung  d.  Augenent- 
ziindung  d.  Neugeborenen,  1884. 


SCLEREMA  AND  EDEMA  299 

disinfection  of  the  eye,  and  the  reduction  of  inflammation  by  cold  applica- 
tions. In  the  mild  cases,  not  'of  gonorrheal  natm'e,  all  that  is  required 
is  to  wash  the  eye  thoroughly  several  times  a  day  with  a  saturated  solu- 
tion of  boric  acid  dropped  into  it  from  a  blunt-pointed  medicine  dropper. 
In  the  gonorrheal  cases  the  treatment  must  be  more  energetic.  The 
lids  should  be  separated,  and  the  boric  acid  solution  in.stilled  every  3^-2 
to  1  hour.  The  solution  should  be  dropped  in  the  corner  nearest  the  nose 
with  the  child's  head  turned  a  little  toward  the  diseased  side  so  that  the 
fluid  may  run  into  the  eye,  and  then  out  as  far  removed  as  possible 
from  the  unaffected  eye.  Care  must  be  taken  that  the  fluid  penetrates 
beneath  the  upper  as  well  as  the  lower  lid.  Thorough  frequent  removal 
of  pus  must  be  accomplished  in  this  way,  since  the  retention  of  the  secre- 
tion is  very  harmful.  A  solution  of  corrosive  sublimate  of  a  strength  of 
1: 10,000  may  be  used  instead  of  boric  acid.  In  addition  to  the  wash- 
ing there  should  be  instilled  into  the  eye  once  a  day  2  or  3  drops  of  a  1  per 
cent,  solution  of  nitrate  of  silver;  or  a  10  to  25  per  cent,  solution  of  protargol 
or  argyrol  more  frequently.  To  reduce  the  inflammation  and  swelling  of 
the  eye  cold  compresses  must  be  applied.  These  are  best  made  of  little 
squares  composed  of  1  or  2  layers  of  soft  linen  cloth  cooled  on  a  block  of 
ice,  and  changed  every  2  or  3  minutes  for  30  minutes  or  more,  with  inter- 
missions of  2  or  3  hours.  In  very  bad  cases  the  application  must  be  kept 
up  continuously  until  the  swelling  has  abated.  Gonorrheal  ophthalmia 
is,  however,  such  a  serious  affection  that  whenever  possible  the  treatment 
is  more  safely  entrusted  to  an  opthalmologist. 


CHAPTER  XIV 

SCLEREMA  AND  EDEMA 

SCLEREMA  NEONATORUM 

(Sclerosis;  Scleroma  Sclerema;  adiposiim) 

Probably  several  different  conditions  were  formerly  considered  to 
be  identical  with  that  v/hich  we  now  designate  as  sclerema.  The  affec- 
tion is  sometimes  wrongly  called  scleroderma,  which  is  at  present  believed 
to  be  entirely  distinct  from  this.  Sclerema  neonatorum  in  its  modern 
sense  appears  first  to  have  been  described  by  Uzembezius.^ 

Etiology  and  Pathology. — Although  not  a  common  disease  any- 
where, it  is  seen  much  more  frequently  in  Europe  than  in  America. 
Writing  in  1897,^  I  was  able  to  discover  but  5  undoubted  and  fully  de- 
tailed cases  published  in  the  United  States,  and  to  these  I  added  a  Gth, 
and  later  reported  another.'  It  is  most  often  seen  in  premature  or  in 
greatly  debilitated  new-born  infants,  living  under  very  unfavorable  hygi- 
enic conditions,  and  it  has  occurred  oftenest  in  institutions  for  found- 
lings. At  a  slightly  later  period,  in  infants  a  few  weeks  or  months  old, 
it  occasionally  develops  following  a  severe  diarrheal  affection  or  other 
exhausting  disease.  The  nature  of  the  change  wiiich  takes  j^hice  is  un- 
determined.    An  explanation  with  much  in  its  favor  is  that  the  great 

1  Ephemerides  naturiB  curiosoruin,  1722.  Rcf.  Hennig,  Gerhardt's  Ilaiidb. 
d.  Kinderkr.,   1877,  II. 

2  Medical  News,   1897,  Oct.  2. 
'Arch,  of  Ped.,  1906.,  Feb. 


300  THE  DISEASES  OF  CHILDREN 

lowering  of  the  body  temperature  dependent  upon  the  condition  of 
inanition  present  produces  a  hardening  of  the  subcutaneous  adipose 
tissue  (Knopf elmacher).^  That  this  can  occur  might  be  due  to  the  low 
percentage  of  olein  and  the  high  percentage  of  stearin  and  palmatin  in  the 
fat  of  infants,  and  the  consequently  higher  melting  point  as  compared 
with  the  fat  of  adults.  Yet  it  is  to  be  noted  that  the  great  majority  of 
new-born  infants  who  develop  collapse-temperatures  do  not  suffer  from 
sclerema.  Various  microorganisms  have  been  considered  to  be  the  active 
causative  agents,  but  the  existence  of  any  such  influence  is  very  uncertain. 
The  etiology  is  still  undetermined. 

Pathological  Anatomy. — There  are  no  characteristic  lesions. 
Incision  of  the  skin  is  not  followed  by  any  exudation  of  blood  or  serum 
as  in  edema  neonatorum.  The  subcutaneous  connective  and  fatty 
tissues  appear  unusually  dry.  Microscopical  examination  showed 
nothing  whatever  abnormal  in  a  case  reported  by  Northrup,^  while 
Ballentyne^  discovered  a  growth  of  bands  of  connective  tissue  and  an 
atrophy  of  the  fat  cells,  and  the  connective-tissue  hypertrophy  was  con- 
firmed by  Sarbonat.^ 

Symptoms. — The  two  characteristic  symptoms  are  fall  of  tem- 
perature and  a  hard  swelling  of  a  portion  of  the  skin.  Occasionally  at' 
birth,  but  oftener  when  the  greatly  debilitated  child  is  a  few  days  old, 
induration  of  the  skin  is  discovered.  This  change  begins  usually  in  the 
feet  and  calves  and  rapidly  spreads  perhaps  over  the  whole  body.  It 
is  usually  most  decided  in  the  cheeks,  buttocks,  back  and  thighs.  The 
swollen  tissues  seem  to  have  an  almost  stony  coldness  and  hardness  and 
will  not  pit  on  pressure.  The  limbs,  and  sometimes  the  whole  body, 
are  more  or  less  stiff  and  immovable.  The  skin  cannot  be  lifted  from  the 
subcutaneous  tissue.  It  is  pale,  waxy,  and  sometimes  in  places  discol- 
ored bluish  or  yellowish,  resembling  an  old  bruise.  The  temperature  of 
the  body  is  generally  very  low,  sometimes  not  over  90°F.  (32.2°C.)  in  the 
axilla,  or  even  less  than  this.  The  child  has  an  almost  inaudible  cry. 
The  respiration  and  cardiac  action  are  very  feeble;  the  fontanelle  is 
sunken;  the  infant  becomes  somnolent  and  will  not  take  nourishment. 
Exceptionally  the  disease  is  complicated  by  edema  (Parrot).^  Atelectasis 
is  very  prone  to  develop. 

Occasionally  cases  are  not  so  severe,  the  temperature  is  not  so  low, 
nor  does  the  child  show  so  great  a  degree  of  inanition  and  debility. 

Prognosis. — This  is  extremely  unfavorable.  The  great  majority 
of  cases  die  in  a  few  days.  Occasionally  when  the  disease  is  not  too 
extensive,  the  general  condition  of  the  infant  is  better,  and  treatment 
commenced  early,  recovery  will  slowly  take  place.  I  have  observed  at 
least  3  such  recoveries  in  cases  which  seemed  to  be  properly  designated 
sclerema. 

Diagnosis. — Sclerema  is  to  be  distinguished  by  the  adherence  of 
the  skin  to  the  subcutaneous  tissues  and  the  fact  that  it  cannot  be 
pitted,  the  very  low  temperature,  and  the  marked  rigidity  of  the  body. 
The  first  two  symptoms  serve  to  distinguish  it  from  edema.  Sclero- 
derma is  generally  considered  a  disease  of  adults,,  but  it  is  possible  that 
some  of  the  milder  cases  called  sclerema  may  properly  be  placed  in  this 

Mahrbuch  fur  Kjnderheilkunde,   1897,  XLV,   177. 
2  Transactions  American  Pediatric  Society,   1889. 
^  .\ntenatal  Pathology  and  Hygiene,   1902,  I,  75. 
^  Arch,  de  med.  des  enf.,   1906,  IX,  22. 
*  La  clinique  des  nouveau-nes,   1877,   127. 


i 


EDEMA  NEONATORUM  301 

category.  In  scleroderma  the  process  of  hardening  is  more  local,  the 
course  is  chronic  and  there  are  no  general  nutritional  symptoms  or  fall 
of  temperature.     (See  studies  by  Cockayne^  and  by  ]\Iayerhofer.-) 

Treatment. — The  only  treatment  possible  is  the  maintenance  of 
the  bodily  temperature,  the  employment  of  general  massage  with  oil, 
and  the  sustaining  of  life  by  food  and  stimulants.  The  continuous  appli- 
cation of  hot  water  bags  to  the  affected  regions  have  been  of  benefit  in 
some  of  the  milder  cases,  and  Wolff*  has  had  good  results  in  severer 
cases  by  submitting  the  infant  to  a  continued  temperature  of  40°to42°C. 
(104°  to  107. 6°F.).  The  original  cause,  if  discovered,  and  complications, 
especially  atelectasis,  must  receive  treatment  appropriate  for  them. 

EDEMA  NEONATORUM 
(Scleredema.    Acute  Edema) 

Although  edema  from  various  causes  may  develop  in  infancy,  there 
is  a  form  oftenest  seen  in  the  new  born  to  which  the  name  of  Edema  Neo- 
natorum is  given.  This  condition  is  considered  by  some  writers  to  be  an 
edematous  form  of  sclerema. 

Etiology. — The  disease  is  uncommon.  In  some  cases  septic  infec- 
tion appears  perhaps  to  have  been  responsible  and  in  others  the  existence 
of  a  specific  infectious  agent  has  been  suspected.  Exposure  to  cold  has 
also  been  considered  to  be  sometimes  the  cause.  It  is  more  likely  to 
develop  in  weakly  or  premature  children,  in  foundling  asylums,  or  under 
bad  hygienic  conditions,  but  hearty  infants  are  exceptionally  attacked. 
Disturbance  of  the  respiratory  and  circulatory  functions  and  beginning 
nephritis  have  each  been  considered  the  causative  agent. 

There  has  further  been  described  by  Schridde^  and  the  observation 
confirmed  by  others  (Chiari;'  Wienskowitz'')  a  special  form  of  widespread 
edema  which  is  congenital  and  which  has  been  designated  by  Chiari 
"fetal  erythroblastosis,"  characterized  by  a  universal  anasarca;  hj'drops  of 
the  serous  cavities ;  enlargement  of  the  liver  and  spleen ;  a  very  large  num- 
ber of  erythroblasts  in  the  blood,  with  a  great  diminution  of  other  ele- 
ments; numerous  erythroblasts  in  the  liver,  spleen,  kidneys  and  other 
organs;  and  an  abnormal  deposit  of  hemosiderin  in  the  spleen  and  liver. 
This  form  of  edema  is  seen  chiefly  in  premature  infants  born  of  mothers 
with  nepliritis,  which  has  been  the  cause  probably  of  a  toxic  disturbance 
of  the  blood-making  functions. 

Pathological  Anatomy. — The  skin  is  hard  as  in  sclerema,  but  in- 
cision into  it  after  death  allows  a  serous  fluid  which  is  colorless,  or  of  a 
slightly  bloody  tint  exuding  from  the  subcutaneous  tissue.  The  other 
findings  in  the  skin  are'  uncharacteristic  and  vary  with  the  case.  The 
lesions  of  the  form  described  by  Schridde  have  already  been  mentioned. 
The  alterations  in  other  parts  of  the  body  are  chiefly  those  of  atelectasis 
and  inanition. 

Symptoms. — In  the  congenital  cases  a  universal  edema  is  seen  at 
birth.  In  other  cases  the  disease  usually  begins  in  the  first  3  or  4  days 
of  life,  although  sometimes  not  until  the  infant  is  some  weeks  or  even 

1  Brit.  Journ.  Child.   Dis.,   1916,  XIII,  -225. 
2.Jahrb.  f.  Kinderh..   191.5,  LXXXI.  .34S. 
»  Monatsschr.  f.   Kinderh.      Ref.,    1014.   XIV,   (id. 
*  .MiuK-h.    mod.   Wochensdir.,    1910,  LVll,  397. 
^.lahrb.  f.   Kinderh..    1914,   LXXX,   .5(31. 
8Berl.  klin.  Wochenschr.,  1914,  Li,  1725. 


302  THE  DISEASES  OF  CHILDREN 

1  or  2  years  old.  It  is  ushered  in,  as  a  rule,  by  swelling  of  the  calves,  which 
rapidly  spreads  over  the  lower  extremities  and  in  the  course  of  at  most 

2  or  3  days  over  the  rest  of  the  body.  The  skin  is  pale,  shining  and  tense. 
Pressure  gives  a  doughy  sensation  and  produces  pitting.  The  skin  is 
not  immovable  over  the  underlying  tissues  as  in  sclerema.  The  limbs 
are  very  cold,  stiff  and  difficult  to  move;  the  face  is  stiff  and  expression- 
less. The  infant  is  in  a  condition  of  collapse,  with  feeble  pulse  and  respi- 
ration, feeble  cry,  inabihty  to  suck,  very  low  bodily  temperature,  and 
diminished  secretion  of  urine.  At  first  there  is  restlessness,  but  finally 
a  soporous  state.  In  fatal  cases  the  condition  gradually  grows  worse 
with  rapid  wasting,  and  the  child  dies  after  a  few  days,  or  at  most  1 
or  2  weeks.  The  disease  may  be  complicated  by  pneumonia,  atelectasis 
or  septic  conditions.  It  may  also  occur  in  connection  with  sclerema. 
Icterus  and  gastrointestinal  disturbances  may  be  present. 

Prognosis. — The  prognosis  of  edema  neonatorum  is,  as  a  rule,  bad. 
Cases  recover  but  rarely. 

Diagnosis. — The  disorder  resembles  sclerema  in  many  particulars. 
It  is  distinguished  from  it,  however,  by  the  ability  to  pit  the  skin  and  to 
move  it  over  the  underlying  tissues.  It  is  to  be  remembered  alqo  that  an 
edema  is  seen  in  erysipelas  and  in  acute  nephritis  in  the  new  born,  and  is 
not  uncommon  in  advancing  marantic  states  in  many  infants.  In  the 
latter  condition,  however,  the  dropsy  comes  on  more  slowly,  and  is  seen 
oftenest  about  the  ankles,  hands  and  scrotum,  although  sometimes  in 
the  face  as  well.  The  temperature,  too,  is  usually  not  so  low,  and  the 
cause  of  the  edema  is  generally  evident. 

Treatment. — The  condition  can  better  be  prevented  than  cured. 
Feeble  children  must  be  kept  warm,  and  nourished  in  the  best  manner 
possible,  and  all  depressing  diseases  treated  energetically.  If  edema 
has  already  developed  these  same  methods  are  still  to  be  employed. 
Alcoholic  stimulation  and  remedies  to  sustain  the  heart's  action  are 
necessary,  together  with  gentle  massage  of  the  body  with  oil.  Compli- 
cations require  treatment  appropriate  to  them. 


CHAPTER  XV 

TRANSITORY  FEVER  IN  THE  NEW  BORN 

(Inanition -Fever;  Hunger-Fever;  Thirst-Fever,  etc.) 

The  natural  irregularity  of  the  temperature  in  the  early  weeks  of  hfe 
readily  predisposes  to  a  febrile  elevation  from  very  slight  causes.  Tempo- 
rary rises  of  temperature  are  probably  much  more  frequent  than  is  usually 
supposed;  the  mistake  being  the  result  of  the  common  absence  of  any 
systematic  temperature-taking  in  infants  which  appear  to  be  in  health. 
Thus  Lo  Cicero^  by  making  observations  on  83  infants  every  3  hours 
during  the  first  8  days  of  life  found  that  in  49  there  were  sudden  rises  of 
temperature  to  from  37.5°  C.  to  39°C.  (99.5°  to  102.2°F.),  with  sudden 
falls,  without  any  objective  signs  except  somnolence  or  sometimes  rest- 
lessness. Eross^  noted  elevation  of  temperature  in  431  out  of  956  new- 
born infants,  viz.;  45.08  per  cent. 

1  La  Pediatria,  1915,  XXIII,  768. 

2  Jahrb.  f.  Kinderh.,  1891,  XXXII,  68. 


TRANSITORY  FEVER  IX    THE  NEW  BORN 


303 


The  fever  usually  appears ,  from  the  2d  to  the  4th  day  of  life.  The 
elevation  may  last  but  a  few  hours  or  continue  for  several  days.  (Fig. 
50).  The  general  condition  of  the  infant  seems  to  be  but  little  influenced, 
children  strong  and  of  good  weight  at  birth  being  affected  as  readily  as 
others.  The  causes  are  not  clearly  understood.  That  thef  ever  is  of 
so  transitory  a  nature  and  without  discoverable  lesions  largely  eliminates 
such  factors  as  general  sepsis,  pneumonia,  and  other  grave  inflammatory 
conditions;  although  Eross  believed  that  in  many  instances  the  elevation 
depends  upon  a  slight  temporary  infection  from  local  putrefactive  changes 
in  the  umbilical  cord,  and  in  others  upon  a  disturbance  of  the  digestive 
tract.     This  explanation  doubtless  applies  to  a  number  of  cases;  but  the 


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FiQ.  50. — Transitory  Fever  in  the  Newborn. 
Baby  M.,  born  Nov.  29.     Persistent  fever  and  loss  of  weight.     Weighing  before  and 
after  each  nursing  showed  an  insufficient  amount  of  milk  furnished.     After  supplemental 
feeding  was  commenced  Dec.  6  the  temperature  fell  and  gain  in  weight  began. 


rapid  development  .of  the  rise  of  temperature  and  its  rapid  disappearance, 
as  well  as  the  uniform  occurrence  at  the  same  period  of  life,  makes  it 
unlikely  that  the  majority  of  cases  can  be  attributed  to  such  causes. 
It  has  also  been  maintained  that  the  fever  depends  upon  irritation  of  the 
kidneys  by  uric  acid  present  in  them,  but  there  is  lacking  sufficient  evi- 
dencOiin  support  of  this  view.  The  fact  that  the  fever  is  liable  to  dcvek)p 
at  the  time  when  the  initial  loss  of  weight  is  at  its  greatest  is  a  suggestion 
that  it  may  be  associated  with  a  condition  of  inanition  from  hunger 
(Holt)^  or  may  depend  upon  thirst  with  consequent  dcssication  of  the 
tissues  (Miiller).^  Those  infants  who  lose  most  in  weight  are  the  ones 
oftenest  showing  elevation  of  temperature.     It  has  been  found,  too,  that 

lArch.  of  Ped.,   1895,   XII,  5G1. 

2  Bed.  klin.  VVochenschr.,  1910,  XL\'ll,  G73. 


304  THE  DISEASES  OF  CHILDREN 

the  giving  of  breast-milk  freely,  or  even  of  water,  will  often  cause  the  fever 
to  disappear  promptly.  There  seems  every  reason  to  believe  that  these 
causes  are  operative  in  many  instances;  but  against  the  view  that  they 
are  the  sole  cause  is  the  fact  that  in  hunger-states  after  the  period  from 
the  2d  to  the  4th  day,  the  starving  infant  with  drying  tissues  is  more  liable 
to  exhibit  subnormal  bodily  temperature.  The  fact  that  the  fever  ap- 
pears, as  stated,  only  upon  certain  days  of  life,  and  that  it  does  not  attack 
with  greater  frequency  those  already  feeble  or  of  low  temperature  at  birth, 
would  support  the  suggestion  which  has  been  made  that  it  may  depend 
upon  an  autointoxication,  the  result  of  some  of  the  physiological  processes 
which  are  especially  active  at  this  time,  and  that  the  giving  of  water  or 
breast-milk  freely  may  act  not  directly  by  relieving  hunger  or  thirst  and 
consequent  inanition,  but  by  favoring  a  washing  out  of  these  toxic  prod- 
ucts from  the  system. 

The  symptoms  attending  transitory  fever  are  more  or  less  char- 
acteristic. The  appetite  is  often  diminished,  and  the  children  nurse 
poorly  from  the  breast  or  the  bottle.  In  other  cases  they  suck  with  avidity 
and  an  evidence  of  hunger.  There  is  restlessness  or  in  more  severe  cases 
prostration  and  little  movement.  Loss  of  weight  continues  while  the 
fever  lasts,  and  is  usually  greater  than  in  normal  infants.  The  tempera- 
ture reaches  39°C.  (102. 2°F.)  or  often  more.  Its  duration  is  2  to  3  days, 
sometimes  with  intermissions,  and  the  fall  is  generally  rapid. 

The  prognosis  is  good  in  the  majority  of  cases,  except  that  the 
continued  and  increasing  loss  of  weight  may  exert  a  serious  influence  upon 
the  infant,  and  even  predispose  to  a  fatal  termination  if  any  other  affec- 
tion arises.  The  diagnosis  is  on  this  account  very  important.  A  care- 
ful examination  will  generally  reveal  the  causes  of  fever  of  any  other 
nature  than  that  now  under  consideration,  and  such  an  examination  must, 
of  course,  invariably  be  made.  Septic  inflammation,  if  other  than  purely 
local,  is  generally  excluded  by  the  disposition  to  develop  at  a  slightly 
later  period;  although  this  is  by  no  means  an  invariable  rule.  The  fever 
also  is  not  of  such  short  duration  and  the  infant  seems  more  ill.  The 
treatment  in  all  cases  dependent  upon  insufficient  food  or  liquid  is 
simple.  In  addition  to  the  free  supply  of  breast-milk  or  of  water,  other 
measures  are  entirely  symptomatic. 


SECTION  HI 
THE  INFECTIOUS  DISEASES 


CHAPTER  I 

GENERAL 
DEFINITION 


Much  confusion  has  existed  regarding  the  employment  of  the  terms 
"infectious"  and  "contagious"  as  apphed  to  disease.  In  the  widest 
sense  an  "infectious"  disease  is  one  due  to  a  specific  hving  organism 
of  some  sort  which  "infects"  the  human  body:  while  "contagious" 
indicates  merely  that  the  disease  may  be  contracted  by  one  individual 
by  contact,  directly  or  indirectly,  with  another.  As  a  matter  of  fact 
most  of  the  infectious  diseases  are  contagious  also.  A  notable  exception 
to  this  is  seen  in  the  case  of  malaria.  Certain  diseases,  such  as  some 
of  those  dependent  upon  the  presence  of  various  parasites  in  the  gastro- 
enteric tract,  the  contagious  parasitic  affections  of  the  skin,  and  certain 
others,  while  clearly  infectious  in  the  broader  sense  are  not  ordinarily 
classified  among  the  acute  infectious  disorders;  that  term,  in  the  narrower 
sense,  and  for  the  sake  of  convenience,  being  reserved  for  those  dependent 
upon  a  more  general  infection  of  the  human  organism  by  microscopic 
germs,  in  which  the  symptoms  are  of  a  more  general  nature.  Those 
with  a  comparatively  short  and  self-limited  course  are  called  the  "acute 
infectious  diseases;"  or,  if  febrile,  the  "acute  infectious  fevers."  The 
others  are  designated  "chronic  infectious  diseases".  Many  of  the  first 
class  are  attended  by  special  cutaneous  eruptions,  and  to  those  the  title 
"acute  exanthemata"  is  often  applied.  The  course  of  the  infectious 
diseases  is  often  marked  by  certain  stages  or  periods  designated  by  special 
terms.  That  during  which  the  germs  are  developing  in  the  body  without 
characteristic  manifestations  is  called  the  period  of  incubation.  On  this 
follows  the  prodromal  stage  or  period  of  invasion,  during  which  the  initial 
symptoms  appear.  After  this  is  the  stage  of  the  fully  developed  disease, 
or  stage  of  florition,  in  the  case  of  the  exanthemata  called  the  period  of 
eruption.  Last  comes  the  stage  of  decline,  in  the  eruptive  fevers  some- 
times designated  the  period  of  desquamation. 

Any  accurate  classification  or  even  enumeration  of  the  infectious 
disorders  is  impossible  at  this  time  of  rapidly  advancing  knowledge 
regarding  them.  The  list  is  constantly  growing.  Among  them  are 
included  here:  scarlatina;  rubeola;  rubella;  variola;  vaccinia;  varicella; 
typhoid  fever;  erysipelas;  cerebrospinal  fever;  diphtheria;  grippe;  per- 
tussis; mumps;  malaria;  tetanus;  and  poliomyelitis.  The  chronic  in- 
fectious diseases  include  tuberculosis  and  syphilis. 

Pneumonia  appears  to  be  quite  certainly  an  infectious  disorder, 
rheumatism  and  perhaps  chorea  probably  so  as  well;  but  for  the  sake 
of  convenience  and  for  other  reasons  I  have  considered  them  elsewhere. 
So,  too,  certain  intestinal  infections,  such  as  cholera  and  some  forms 
of  enterocolitis,  are  clearly  infectious  and  coninumicable;yct  they  are  more 

20  305 


306  THE  DISEASES  OF  CHILDREN 

conveniently  studied  in  tli3  section  on  Diseases  of  the  Intestine.  The  septic 
infections  of  the  new  born  have  for  the  most  part  ah'eady  been  described 
in  a  preceding  section,  and  gonorrhea  is  discussed  under  the  headings 
of  the  organs  affected. 

At  times  two  or  even  more  acute  infectious  diseases  may  affect  a  patient 
simultaneous!}^  or  one  shortly  after  the  other.  The  following  of  pertussis 
upon  rubeola  is  of  great  frequency,  and  the  development  of  diphtheria 
with  or  immediately  after  scarlet  fever  or  especially  measles  is  also  often 
seen.  Measles  and  scarlet  fever  may  occasionally  occur  together,  and 
even  epidemics  of  this  have  been  reported.  The  combination  of  typhoid 
fever  with  scarlet  fever  is  less  often  reported,  and  that  of  typhoid  fever 
with  measles  still  less  frequently.  In  one  instance  I  saw  rubeola  and 
diphtheria  with  varicella  which  took  on  a  gangrenous  form  occur  nearly 
simultaneously,  and  in  another  typhoid  fever,  measles  and  cerebrospinal 
fever. 

METHOD  OF  DISSEMINATION 

The  older  views  were  long  accepted  without  question  that  the  chief 
means  of  the  dissemination  of  the  germs  of  infectious  diseases  was  by  the 
air-current,  the  dust  of  the  room,  the  playthings,  books  and  clothing 
of  the  patient,  and  the  clothing  of  attendants  or  other  third  persons. 
More  careful  study  of  recent  years  has  proven  with  fair  satisfaction  that, 
although  these  methods  are  theoretically  possible,  in  practice  they  occupy 
a  very  limited  position.  The  transmission  by  a  third  person  is  practi- 
cally only  by  the  direct  handling  of  a  child,  as  by  a  nurse  who  has  just 
left  an  infectious  patient  close  by.  This  could  take  place  only  with  great 
carelessness  and  in  hospital  wards.  The  chief  source  of  infection  is 
close  contact  with  or  proximity  to  the  patient  himself,  the  disease  being 
communicated  to  others  either  before  it  has  been  recognized  and  the 
individual  isolated,  or  given  after  quarantine  has  been  removed  and  the 
patient  believed  to  be  well.  It  is  usually  by  means  of  the  mucous  secre- 
tion of  the  infected  person;  often  through  the  microscopic  drops  of 
mucus  which  are  coughed  or  sneezed  out  by  the  patient  or  carried  upon 
the  breath;  these  reaching  the  respiratory  tract  of  the  previously  healthy 
individual.  In  numerous  instances  the  disgrder  has  been  perhaps  so 
mild  that  it  has  not  been  recognized  at  all,  and  the  child  has  remained 
an  undiscovered  source  of  infection.  Those  who  have  recovered  from 
an  infectious  disease,  but  who  still  harbor  its  active  infectious  germs  are 
called  "carriers,"  and  the  same  title  is  applied  to  the  smaller,  but  still 
quite  large  class  comprising  those  who  have  not  suffered,  but  who  have 
been  in  close  contact  with  patients,  and  who  carry  the  germs  upon  their 
muocus  membranes.  It  is  almost  solely  in  this  way  that  the  disease  is 
transmitted  by  a  third  healthy  person,  and  the  danger  is  probably  less 
than  from  those  who  have  suffered  from  the  disease.  The  possibihty  of  the 
dissemination  by  dust,  water,  insects,  and  in  other  ways  will  be  considered 
under  the  headings  of  the  various  infectious  diseases.  It  varies  with 
the  disease;  tuberculosis,  for  instance,  being  undoubtedly  readily  spread 
by  dust  upon  the  hands  or  in  the  food;  typhoid  fever  by  water  and  by 
insects. 

GENERAL  RULES  FOR  THE  HYGIENIC  CARE  AND  THE  QUARANTINE  OF 

INFECTIOUS  DISEASES 

The  diseases  under  consideration  vary  greatly  in  their  relative  in- 
fectiousness, and  in  the  mode  by  which  the  germs  are  chiefly  conveyed. 
The  following  rules  are  those  to  be  applied  where  rigorous  prophylactic 


HYGIENIC  CARE  AND  QUARANTINE  OF  INFECTIOUS  DISEASES     307 

measures  are  to  be  carried  out.  Circumstances  may  alter  either  the 
possibihty  or  the  necessity  of  their  appUcation.  It  must  be  understood 
clearly  that  the  methods  to  be  described  constitute  in  some  respects 
the  ultimate  limit  of  precautions  to  be  followed;  not  those  which  are 
considered  by  the  leading  authorities  as  actually  necessary.  It  has, 
for  instance,  repeatedly  been  shown  in  hospital  practice  that  it  is  per- 
fectly possible,  with  proper  precaution  by  the  aid  of  the  "box  method," 
to  treat  different  infectious  diseases  in  the  general  wards  without  extension 
taking  place.  (See  Koplik,'  von  Pirquet,-  Richardson,^  and  Bundle 
and  Burton^  on  the  Box  System  and  similar  methods  in  hospital  practice.) 
However,  inasmuch  as  the  requirements  of  local  Boards  of  Health  vary 
and  are  often  rigorous,  and  since  our  knowledge  of  the  method  of  spread 
of  infectious  diseases  is  still  incomplete,  it  is  better  to  err  upon  the  safe 
side,  and  the  full  details  of  quarantine  may  well-be  described. 

Room. — The  room  selected  should  be  preferably  in  the  upper  portion 
of  the  house.  Here  the  patient  is  less  liable  to  be  disturbed  bj''  noises, 
and  here,  too,  isolation  can  be  better  carried  out.  It  should  be  well- 
lighted  and  well- warmed,  and  capable  of  being  well-ventilated.  It 
should  open  into  another  room,  which  we  may  call  the  anteroom.  This 
should  be,  if  possible,  a  bath-room  or  a  room  opening  into  it.  The 
temperature  of  the  sick-room  should  be  from  65  to  70°F.  (18.3°  to  21.1°C.). 
The  door  entering  it  from  the  hallway  should  be  locked,  and  the  cracks 
stuffed  with  paper  or  cotton.  The  door  from  the  anteroom  into  the 
hallway  should  be  kept  closed  except  at  the  time  of  exit  or  entry.  A  sheet 
should  be  hung  here  which  should  be  kept  moistened  with  a  solution  of 
corrosive  sublimate  (1:1000)  or  one  of  carbolic  acid  (5  per  cent.). 
The  real  value  of  this  measure  against  the  spread  of  the  disease  is  more 
than  questionable,  but  it  serves  at  least  as  a  reminder,  and  satisfies 
the  demands  of  some  Boards  of  Health. 

Ventilation  is  best  obtained  by  a  fireplace,  or,  in  the  absence  of  this, 
from  the  anteroom.  Screens  should  be  used  at  the  windows  of  the  sick- 
room to  prevent  the  direct  action  of  draughts  upon  the  child  and  the 
entrance  of  insects.  If  the  weather  permits,  the  window  of  the  anteroom 
should  be  opened  constantly,  thus  practically  cutting  off  the  sick-room 
from  the  rest  of  the  house.  It  is  to  be  understood  that  the  action  of 
draughts  in  producing  chilling  of  the  surface  and  any  consequent  damage 
s  not  so  much  to  be  feared  during  the  febrile  state  of  the  disease.  It  is 
after  fever  is  past  that  injury  may  follow. 

The  sick-room  should  have  all  unnecessary  articles  removed,  espe- 
cially all  clothing,  carpets,  curtains,  upholstered  furniture,  and  pictures. 
Only  such  books  and  toys  may  remain  as  shall  afterward  be  destroyed. 
The  room  should  be  kept  very  clean,  all  dust  being  removed  by  wiping 
with  a  1  :  1000  bichloride  solution.  The  solution  nnist  not  be  used 
upon  metal. 

Patient. — The  food  for  the  patient  and  nurse  should  be  brought  to 
the  door  of  the  anteroom  bj''  an  attendant.  After  the  dishes,  spoons  or 
other  articles  have  been  used,  they  should  be  washed,  and  either  boiled, 
or  disinfected  with  a  5  per  cent,  solution  of  carbolic  acitl  in  which  they 
should  lie  for  some  time.  All  bed-clothes  and  body-clothing  should  bo 
changed  freciucntly  and  should  be  inunerscd  in  a  5  per  cent,  solution  of 

•Arch,  of  Ped.,   1911,  XXVIII,  728;  1912,  XXIX,  5. 

2  Zeitschr.  f.   Kindcrh.,  Orig.,   1913,  V,  213. 

3  Jour.  Aincr.   Med.  A.ssoc,   1913,  LXI,   1882. 
*  Lancet,   1912,  1,  720. 


308  THE  DISEASES  OF  CHILDREN 

carbolic  acid  or  a  1  :  1000  solution  of  corrosive  sublimate  kept  in  the 
anteroom.  After  thorough  soaking  they  should  be  wrung  out,  placed  in 
aibucket  and  taken  by  an  attendant  from  the  nurse  at  the  door  of  the 
anteroom.  They  may  now  be  washed  with  the  other  linen  of  the  house 
without  danger.  Old  linen  or  muslin  cloths  and  absorbent  cotton  may 
well  replace  handkerchiefs,  since  they  can  be  destroyed  at  once  after 
use.  The  utmost  care  should  be  taken  to  receive  and  disinfect  or  de- 
stroy promptly  all  discharges  from  the  eyes,  nose,  mouth  and,  in  the  case 
of  typhoid  fever,  the  intestine  and  bladder.  When  there  is  free  ex- 
pectoration, paper  sputum-cups  or  others  holding  a  5  per  cent,  solution 
of  carbolic  acid  may  be  employed. 

Attendants. — The  nurse  should  be  dressed  in  washable  material, 
and  should  have  a  cap  to  cover  thoroughly  the  hair  and  the  neck.  She 
should  have  her  meals  in  the  sick-room  or,  better,  anteroom,  and  leave  it 
only  when  about  to  pass  through  the  house  on  her  way  out.  Before  doing 
this  she  should  slip  off  her  outer  garment,  disinfect  her  hands  and  face 
with  a  2  per  cent,  solution  of  carbolic  acid  or  a  1  :  5000  of  corrosive  subli- 
mate, put  on  her  outer  street  clothes,  which  should  be  kept  in  the  anteroom, 
and  go  directly  out  wdthout  stopping  to  talk  with  members  of  the  family. 
Those  of  the  family  who  must  necessarily  enter  the  room  to  relieve  the' 
nurse  should  adopt  similar  precautions.  With  proper  care  the  confine- 
ment of  the  nurse  to  the  sick-room  during  the  whole  of  the  disease 
is  entirely  unnecessary  and  constitutes  a  superfluous  hardship.  The 
physician  too,  should  on  entering  the  anteroom  array  himself  in  a  linen  or 
rubber  gannent.  A  linen  dust-coat  is  very  serviceable  for  this  purpose. 
He  should  wear  an  oil-silk  or  other  cap  upon  his  head.  Before  leaving 
the  anteroom  he  should  remove  these  articles,  and  disinfect  his  hands 
and  face  carefully. 

Family.- — Other  non-immune  children  should,  when  possible,  be 
removed  from  the  house,  and  should  not  be  allowed  to  go  to  school  or 
mingle  with  others  until  a  time  has  elapsed  equal  to  the  duration  of  in- 
cubation, for  fear  they  may  have  the  disease  already  in  their  systems. 
If  they  are  obliged  to  continue  to  reside  in  the  house  they  should  not 
attend  school  or  associate  with  other  children  until  the  patient  is  re- 
moved from  quarantine.  In  case,  however,  they  have  already  had  the 
disease,  there  is  no  actual  reason  why  they  may  not  safely  be  with  other 
children  if  the  measures  for  isolation  of  the  patient  are  being  properly 
carried  out.  The  feeling  of  other  parents  regarding  the  matter  is,  how- 
ever, so  strong  that  it  is  useless  to  insist  upon  the  truth  of  this. 

Final  Disinfection. — Wlien  the  disease  is  over  the  child  should 
receive  a  disinfecting  bath  of  corrosive  sublimatel  :  10,000,  particular  atten- 
tion being  paid  to  the  hair.  (See  p.  243.)  He  should  then  be  di'essed  in 
entirelj'  clean  underclothing  and  removed  to  another  room.  The  outer 
clothing  in  use  at  the  time  the  disease  began  should  have  been  meanwhile 
thoroughly  exposed  to  fresh  air  and  sunlight.  The  sick-room  and  all  others 
used  during  the  illness  should  be  thoroughly  disinfected.  The  carpets, 
if  they  have  not  been  removed  previously,  and  the  mattresses  and  pil- 
lows should  be  subjected  to  superheated  steam  in  a  municipal  disinfect- 
ing plant,  when  this  is  practicable.  When  not,  they  may  be  allowed  to 
stay  in  the  room  during  fumigation,  and  then  exposed  to  the  open  air 
and  sunlight  for  several  days.  The  walls,  if  papered,  should  be  scraped, 
and,  if  painted,  washed  with  a  1  :  1000  solution  of  corrosive  sublimate. 
The  floor  should  be  scrubbed  with  soap,  and  then  washed  with  the  solu- 
tion.    The  furniture  should  be  wiped  carefully  with  the  solution,  except- 


SCARLET  FEVER.     SCARLATINA  309 

ing  in  the  case  of  metal,  when  carboHc  acid,  5  per  cent.,  must  be  used 
instead.  All  small  objects,  such  as  toys,  books  and  the  like  should  be 
burned.  Fumigation  with  formaldehyde  has  been  much  in  vogue,  but  is 
being  with  reason  abandoned  in  many  quarters.  As  ordinarily  performed 
it  is  questionable  whether  it  possesses  any  value.  It  may  be  regarded  as 
an  additional  precaution.  Preparatory  to  the  fumigation  the  cracks 
of  the  windows  should  be  plugged  with  cotton,  a  formaldehyde  lamp  or 
candle  started  or  the  solution  scattered  about,  the  outer  door  then  closed 
and  the  cracks  plugged  in  the  same  way,  and  the  room  left  undisturbed 
for  ]2  hours. 


CHAPTER  II 

SCARLET  FEVER 

(Scarlatina) 


History. — Although  by  some  believed  to  have  been  known  to  the 
ancients,  or  at  least  to  early  Christian  or  Arabian  writers,  it  is  more  prob- 
able that  scarlet  fever  was  not  distinguished  from  other  eruptive  fevers 
until  about  the  middle  of  the  17th  century.  At  this  time  Sennert^  gave 
a  good  clinical  description  of  an  epidemic.  Sydenham ^  appears  to  have 
been  the  first  to  distinguish  it  clearly  from  measles,  and  to  apply  to  it  its 
present  name.  The  disease  has  certainly  increased  greatly  in  frequency 
since  the  17th  century,  and  now  is  one  of  the  most  common  of  the  infec- 
tious fevers,  without  any  discoverable  diminution  in  its  incidence 
(Donnally).^ 

Etiology.  Predisposing  Causes. — Climatic  and  geographical  condi- 
tions seem  to  possess  but  little  influence.  The  disease  appears  capable  of 
developing  wherever  the  infection  is  brought,  although  it  still  remains 
far  most  common  in  Europe  and  America.  The  season  of  the  year  is 
perhaps  not  without  importance,  the  greatest  number  of  cases  occurring 
in  the  winter  and  especially  in  the  autumn  months.  This  is,  however, 
a  much  disputed  point,  and  the  influence  of  season,  if  it  exists,  is  certainly 
not  very  considerable. 

Sex,  race,  social  conditions,  and  sanitary  surroundings  possess  no 
certain  predisposing  causal  relationship,  the  statements  regarding  thom 
being  entirely  contradictory.  So,  too,  the  previous  state  of  health  of  the 
patient  has  no  discoverable  connection  with  the  susceptibility,  except 
that  patients  with  wounds  seem  particularly  disposed  to  contract  the 
disease.     (See  Surgical  Scarlet  Fever,  p.  31G.) 

On  the  other  hand,  the  influence  of  age  is  very  great.  Although  the 
disease  may  possibly  occur  congenitally  (Gigon)  ,**  or  may  develop  in  old  age, 
by  far  the  most  frequent  occurrence  is  in  childhood.  The  greatest  number 
of  cases  were  found  by  GresswelP  between  the  ages  of  5  and  10  years,  and 
the  next  between  2  and  5  years.  Donnally'^  in  a  review  based  upon  some 
millions  of  cases  placed  about  50  per  cent,  l^etween  3  and  8  years,  antl  90 
per  cent,  in  the  first  15  years  of  life.     Under  the  age  of  1  year,  and  espe- 

iMed.  pract.  WittcmberK,  1(354,  If,  cup.  12.  Kef.  Rilliot  Jiiid  Harthez  (S;um<5) 
Mai.  des  enf.,  1891,  III,  74. 

2  Processus  IntoKii.     IM.  Williams,  2()tli  Cent.   Pract.  of  Med.,  18l)S,  XIV,  117. 
^Amer.  Jour.  Dis.  Cliild.,  19 U),  X\\,  20."). 
Uahrh.   f.  Ivinderh.,   1910,  LXXII,  ()7(i. 
"A  Contrib.  to  the  Nat.  Hist,  of  Scarlatiiui,    1S90. 
Loc.  cit. 


310  THE  DISEASES  OF  CHILDREN 

cially  under  6  months  it  is  very  much  less  common  than  at  other  periods 
of  early  life.  Gresswell  gives  only  0.6  per  cent,  in  the  1st  year  in  588  cases ; 
Caiger  and  Dudgeon^  0.9  per  cent,  in  167,840  cases  of  the  Metropolitan 
Asylums  Board's  Hospitals,  and  Herberg-  0.6  per  cent,  in  1000  cases. 
Lemarquand^  records  22  personal  observations,  and  gives  a  number  of 
others  from  medical  literature,  in  which  nursing  women  with  scarlet  fever 
did  not  communicate  the  disease  to  their  infants  in  the  early  months  of  life. 
The  j^oungest  patient  under  my  own  observation  was  3  months  of  age. 

The  indivulual  susceptibilitij  to  the  disease  varies  greatly.  Some 
individuals  appear  immune,  although  repeatedly  exposed.  The  disease 
certainly  has  a  less  general  tendency  to  spread  than  some  of  the  other  in- 
fectious disorders  possess.  In  the  experience  in  the  Faroe  Islands  (Hoff),* 
for  instance,  while  99  per  cent,  of  the  population  of  one  of  the  chief  towns 
showed  susceptibility  to  measles,  only  38.3  per  cent,  of  unprotected 
persons  contracted  scarlatina.  In  Boston  during  5  years  the  number  of 
cases  varied  from  16.77  to  62.87  per  10,000  of  the  population  (McCollum).^ 
My  own  experience  has  always  shown  the  spread  of  scarlatina  to  be  much 
more  readily  controllable  than  that  of  measles. 

The  comparatively  small  number  of  cases  occurring  in  early  infancy 
and  after  childhood  is  passed  is  probably  in  part  due,  in  the  first  instance, 
to  a  lesser  frequency  of  exposure,  and,  in  the  second,  to  the  protection 
already  given  by  a  previous  attack.  Still,  a  greater  degree  of  suscepti- 
bility certainly  does  appear  to  exist  in  childhood,  since  in  the  Faroe's 
epidemic,  where  no  previous  immunity  existed,  56.3  per  cent,  of  the  cases 
were  under  20  years  of  age  and  only  7.6  over  40  years. 

An  epidemic  influence  is  also  discoverable.  This  is  especially  seen 
in  country  districts,  for  in  many  of  the  larger  cities  the  disease  is  prac- 
tically endemic,  cases  constantly  appearing  although  in  very  different 
numbers  at  different  seasons  and  in  different  years.  The  severity  of  the 
disease  and  the  consequent  mortality  vary  greatly  with  the  epidemic. 

Of  great  scientific  interest  is  the  much  disputed  possibility  of  the 
experimental  transmission  of  scarlet  fever  to  apes,  particularly  as  bear- 
ing upon  the  possible  etiological  influence  of  the  streptococcus.  While 
successful  transmission  has  been  reported  by  Landsteiner,  Levaditi  and 
Prasek;*^  Bernhardt;^  and  Schleissner,*  this  has  not  been  confirmed  by 
the  studies  of  Draper  and  Hanford;^  Krumweide,  NicoU  and  Pratt;^*^ 
Klimenko,^^  and  others.  It  must  be  concluded  that  the  possibility  of 
transmission  to  animals  still  lacks  definite  proof. 

Exciting  Cause. — The  direct  cause  of  the  disease  is  infection,  and 
analogy  is  convincing  that  this  is  by  means  of  some  form  of  living 
organism.  The  nature  of  the  germ  has  been  much  discussed,  but  still 
remains  disputed.  From  the  time  of  the  report  by  Klein^^  Qf  t,he  strepto- 
coccus  scarlatinae  to  the  present,  various  germs  have  been  described. 

lAllbutt  and  Rolleston's  Svst.  of  Med.,  1906,  II,  1,  429. 
2  Zeitsch.  f.  Heilk.  u.  Infectionskrankh.,  1910,  LXV,  237. 
^  These   de  ParLs,  1906,  July. 

'' Sundhedskolligiets    Aarsberetning- 1876.     Ref.   von    Jiirgensen   in   Nothnagel's 
Encyclopedia,  Amer.  Edit.,  Article  Measles  228;  Scarlet  fever  382. 
*  Boston  City  Hospital  Reports,   1899. 
6  Ann.  de  I'institut.  Pasteur,  1911,  XXV,  754. 
'Deut.  med.  Wochenschr..  1911,  XXXVII,  791. 
sjahrb.  f.  Kinderh.,  1915,  LXXXII,  225. 
8  Jour.   Expcr.  Med.,  1913,  XVII,  517. 
10  Arch.  Int.  Med.,  1914,  XIII,  909. 
".Jahrb.  f.  lunderh.,  1913,  LXXVII,  679. 
12  Proc.  Royal  Soc,  London,  1887,  XLII,   158. 


SCARLET  FEVER.     SCARLATINA  311 

Among  the  different  investigators  Class ^  discovered  a  diplococcus  which 
he  beheved  to  be  pathogenic,  and  Baginski  and  Sommerfeld^  reported  a 
similar  germ  as  being  uniformly  present  in  the  pharynx  and  as  found  in 
the  blood  and  organs  of  fatal  cases.  Salge'^  and  others  have  produced 
agglutination  of  the  scarlatinal  streptococci  by  the  blood  from  a  case  of 
scarlet  fever,  but  Kolmer^  found  agglutinins  and  antibodies  present  in 
only  a  small  percentage  of  cases.  Mallory"  reported  a  protozoan-like 
body,  the  cyclastis  scarlatinalis,  resembling  the  malarial  parasite  and 
found  in  and  between  the  epithelial  cells  of  the  skin  and  in  the  lymph 
vessels  and  spaces  of  the  corium;  and  in  a  later  publication  with  Medlar^ 
described  a  Gram-positive  bacillus  constantly  present  early  in  the  case 
in  the  crypts  of  the  tonsils.  Later  these  disappear  and  are  replaced  by 
streptococci. 

The  chief  point  of  interest  is  connected  with  the  possible  causative 
influence  of  the  streptococcus.  There  is  reason  to  believe,  as  pointed  out 
by  Hektoen,^  Jochmann,^  and  others  that,  although  a  germ  of  this  class 
is  frequently  present,  it  is  rather  the  cause  of  complicating  conditions 
than  of  the  disease  itself.  The  real  nature  of  the  causative  organism  of 
scarlet  fever  appears  to  be  still  unknown. 

Method  of  Transmission. — ^The  disease  never  originates  sponta- 
neously, but  is  always  transmitted  from  the  sick  to  the  well.  The  trans- 
mission is  either  du'ect,  and  this  is  true  of  the  great  majority  of  cases,  or 
mediately  through  clothing,  carpets,  bedding,  and  the  like,  or  a  third 
person.  The  mediate  infection  is  certainly  uncommon.  (See  Infectious 
Diseases,  p.  306.)  The  transmission  occurs  with  great  frequencj'  in 
schools,  where  children  with  the  disease  about  to  manifest  itself,  and 
who  consequently  possess  the  power  of  infecting,  communicate  it  directly 
to  others. 

Numerous  instances  are  on  record  where  the  disease  has  been  carried 
even  for  some  time  and  distance  in  the  clothing  of  physicians  or  nurses, 
or  been  transmitted  by  letters,  toys  and  books,  or  carried  by  animals. 
These  methods  of  dissemination  are,  however,  exceptional.  There  are 
many  instances  of  its  spread  by  milk  coming  from  dairies  where  scarlet 
fever  existed  among  the  families  of  the  employees.  Kober^  found  the 
disease  at  the  dairy  or  milk-farm  in  68  out  of  99  reported  epidemics  of 
scarlet  fever.  Although  instances  are  reported,  it  is  yet  doubtful  whether 
an  immune  inmate  of  a  house  where  scarlet  fever  exists,  who  does  not 
come  into  intimate  association  with  the  patient,  can  transmit  it  to  another 
individual.  Indeed,  close  contact  with  the  patient  or  with  the  infected 
article  seems  to  be  necessary,  as  the  germs  do  not  appear  to  be  carried 
to  any  distance  by  the  air.  The  disease  has  also  been  communicated 
by  direct  inoculation  (Stickler).'*^ 

Seat  of  the  Virus. — ^The  parts  of  the  body  in  which  the  infectious 
matter  is  chiefly  situated  is  a  suljjcct  still  incompletely  detei'inined.  The 
fresh  or  dried  mucus  from  the  nose  and  throat  is  undoubtedly  infectious, 

1  New  York  Med.  Record,  1899,  LVI,  320. 
2Berl.  klin.  Woch.,   1900,  XXXVII,  588. 
3  Munch,  nied.  Woch.,   1902,  Oct.  14. 
■•  Arch.  Int.   Mod.,   1912.   IX,  220. 
*  Journ.  Med.  Research,  1904,  X,  483. 
«  Journ.  Mod.  Rosoarch,  1910,  XXXIV,  127. 

Mourn.  Amor.  Mod.  A.ssoc,  1903,  XL,  0S.5;  1907.  XI.VIII,  li:)S. 
«  Deut.  Arch.  f.  khn.  Mod.,  1908,  LXXIII,  209. 
»  Amor.  Journ.  Med.  Sci.,  1901. 
i»  N.  Y.  Med.  Record,  1899,  LVI,  363. 


312  THE  DISEASES  OF  CHILDREN 

as  is  the  pus  from  a  complicating  otitis,  empj'ema  or  suppurating  adenitis. 
The  infectiousness  of  the  urine  and  feces  is  in  doubt.  It  is  questionable 
whether  the  expired  air  carries  the  germs.  The  scales  of  the  epidermis 
were  formerly  considered  extremely  infectious,  but  this  is  now  much 
disputed,  and  there  is  little  if  any  danger  from  them  except  as  they  may 
be  merely  the  carriers  of  contagious  material  derived  from  the  secretions, 
which  has  attached  itself  to  them.^  It  is  certain  that  the  disease  can  be 
given  by  persons  suffering  from  a  scarlatinal  angina  who  have  never 
exhibited  eruption  or  desquamation. 

Period  of  Maximum  Infectivity. — With  this  uncertainty  as  to  the  chief 
method  of  dissemination  of  the  contagion,  the  question  regarding  the  most 
infectious  stage  must  remain  as  yet  undetermined.  The  ease  with  which 
infection  spreads  in  schools  shows  that  the  latter  portion  of  the  stage 
of  incubation  or  certainly  the  earliest  part  of  the  stage  of  invasion  must 
possess  infectious  power.  Probably  the  most  active  period  is  that  of  the 
height  of  the  eruption.  The  disease  is  also  communicable  during  the 
stage  of  desquamation  and  after  it.  This  is  proved  by  the  frequency 
with  which  it  occurs  in  other  children  in  the  family,  after  patients  who 
have  suffered  from  scarlet  fever  in  hospitals  have  returned  to  their  homes 
("Return  cases").  Thus  Pugh^  found  that  2.9  per  cent,  out  of  6507  hos- 
pital cases  later  communicated  the  disease  to  others  at  home  after  6 
weeks  in  the  hospital.  In  many  of  these  instances  the  virus  had  probably 
persisted  in  the  nasal  or  faucial  secretion  of  a  mucous  membrane  still 
slightly  diseased,  or  in  the  pus  of  a  discharging  ear. 

Tenacity  of  Life. — -The  remarkable  tenacity  of  life  of  the  germs  renders 
difficult  the  solution  of  the  question  of  the  time  of  greatest  infectiousness. 
There  are  numerous  carefully  observed  instances  on  record  which  seemed 
to  prove  that  the  germs  may  live  and  communicate  the  disease  after 
months  or  even  after  several  years.  Murchison^  gives  an  instance  of  the 
persistence  of  vitality  for  4  months;  LommeP  for  133  days;  and  Sanne^ 
for  71  days.  Others  of  still  longer  duration  are  on  record  but  are  open 
to  doubt. 

Pathological  Anatomy.- — ^There  are  no  definite  lesions  characteristic 
of  the  disease  except  that  of  the  skin  and  of  the  mucous  membrane  of  the 
mouth  and  throat.  The  intense  hyperemia  present  during  life  disappears 
after  death.  There  is  found,  however,  a  dilatation  of  the  lymphatics  and 
blood-vessels  of  the  skin  (Pearce),^  with  a  swelling  of  the  cells  of  the  rete, 
sometimes  with  extravasations  of  blood  between  them.  An  infiltration 
of  all  the  layers  of  the  skin  by  serum  and  leucocytes  occurs,  especially  in 
the  corium  and  around  the  hair-follicles,  sweat-glands  and  blood-vessels. 
As  a  result  of  this  process  there  is  a  rapid  destruction  of  the  upper  cells 
of  the  epidermis  which  results  in  desquamation. 

The  mucous  membrane  of  the  mouth  and  throat  suffers  an  analogous 
inflammation  with  desquamation,  especially  well  seen  on  the  tongue  and 
producing,  in  typical  cases,  the  strawberry  appearance.  The  inflamma- 
tion, in  average  cases  merely  catarrhal,  becomes  in  many  instances 
pseudomembranous  or  even  gangrenous  in  the  fauces.  The  pseudo- 
membranous inflammation  of  the  throat  exhibits  various  organisms, 

«  1  Discussion,  Brit.  Med.  Journ.,  1902,  1,  777. 

2  Lancet,  1905,  I,  273. 

3  Lancet,  1864,  II,  176. 

*  Miinch  med.  Wochensehr.,  1901,  XL VIII,  1165. 
6  Rillietand  Barthez,  Mai.  des  enf.,  1891,  III,  164. 
^  Boston  City  Hosp.  Reports,  1899. 


SCARLET  FEVER.     SCARLATINA  313 

generally  streptococci.  It  is  probable  that  the  presence  of  these  germs 
is  the  evidence  of  a  secondary  infection.  The  faucial  inflammation  may 
spread  to  the  nose  and  ears,  and  thence  to  the  mastoid  cells  and  even  the 
meninges. 

There  is  widespread  involvement  of  the  lymphatic  tissue  throughout 
the  body.  This  is  especially  marked  in  the  cervical  lymphatic  glands, 
which  often  suppurate,  the  pus  containing  streptococci.  Swelling  and 
edematous  infiltration  of  the  cellular  tissue  of  the  neck  is  common.  The 
spleen  is  often  enlarged  and  shows  hyperplasia  of  the  lymph  follicles. 
The  lymphatic  tissue  of  the  gastroenteric  tract  is  hyperplastic,  Peyer's 
patches  being  often  much  enlarged  and  prominent. 

Endocarditis  and  pericarditis  are  not  uncommon,  and  pleuritis  and 
pneumonia  may  occur.  Parenchymatous  changes  may  be  found  in 
any  of  the  organs  of  the  body.  These  are  not  characteristic,  but  are  due 
partly  to  the  fever,  as  in  all  febrile  diseases,  partly  to  the  septic  involve- 
ment, and  partly  to  the  direct  action  of  the  scarlatinal  poison.  All  these 
lesions,  as  well  as  the  involvement  of  the  kidneys  so  often  present,  are 
more  conveniently  considered  under  Complications. 

Symptoms.  Typical  Scarlet  Fever.  Period  of  Incubation. — 
This  period,  between  infection  and  the  development  of  the  first  symp- 
toms, is  irregular  within  certain  limits.  In  general  it  may  be  placed 
at  from  1  day  to  1  week,  in  by  far  the  majority  of  cases  from  2  to  4  days. 
Even  periods  of  but  a  few  hours  have  been  recorded  (Russeger).^  On  the 
other  hand,  periods  of  incubation  lasting  12  days  are  not  uncommon,  and 
even  as  much  as  20  days  or  more  are  on  record  (Hagenbach-Burckhardt).- 
As  a  rule  the  danger  of  developing  the  disease  may  be  considered  over 
after  7  days  from  exposure  has  elapsed.  In  cases  of  surgical  scarlet  fever, 
as  for  instance  after  tracheotomy,  the  period  of  incubation  is  usually  very 
short.  Severe  cases  also  appear  to  have  a  shorter  period  of  incubation 
than  others. 

Period  of  Invasion. — The  onset  is  generally  of  great  suddeness.  Ex- 
cept in  older  children  there  is  generally  no  distinct  initial  chill,  although 
there  may  be  chilliness  and  pallor.  Convulsions  are  often  among  the 
first  symptoms  in  quite  young  children.  Vomiting,  often  repeated, 
occurs  at  the  onset  in  the  great  majority  of  cases.  Diarrhea  occasion- 
ally accompanies  it.  The  temperature  rapidly  rises  to  103°  or  104°F. 
(39.4°  or  40°C.)  or  more,  and  the  face  becomes  flushed.  The  pulse  is 
rapid  and  there  is  headache  and  generally  sore  throat,  of  which,  however, 
young  children  often  make  no  complaint.  The  child  looks  and  feels  ill, 
sleeps  badly,  and  is  restless  and  decidedly  prostrated.  The  lymphatic 
glands  of  the  neck  begin  to  enlarge.  The  eruption  is  now  found  in  the 
throat  (enanthem),  giving  a  characteristic  appearance;  the  mucous  mem- 
brane, namely,  of  the  hard  and  soft  palate,  the  tonsils,  and  the  anterior 
pilhirs  of  the  fauces  being  unusually  red,  due  to  the  presence  here  of  closely 
packed  minute  dark-red  macules.  This  condition  rapidly  spreads  to  the 
lining  of  the  cheeks  and  gums.  The  macules  may  be  distinctly  visible  or 
they  may  have  fused  to  such  an  extent  that  only  a  uniform  red  flush  is  per- 
ceptible. The  tongue  is  coatotl  with  the  edges  sometimes  reddened. 
The  tonsils  are  swollen  and  often,  exhibit  whitish  spots  due  to  secretion 
retained  in  the  follicles. 

The  duration  of  the  invasion  is  short,  from  12  hours  or  occasionally 
less  up  to  24  hours.     It  is  of  very  common  occurrence  for  a  child  to  ex- 

» Oestcr.  med.  Jahrb.,  1.S4S,  LXIII,  277. 
2  Jahrb.  f.  Kindorh.,  18SG,  XXIV,  105. 


314 


THE  DISEASES  OF  CHILDREN 


hibit  the  febrile  symptoms  and  vomiting  during  the  night  and  to  be  found 
with  the  eruption  well  developed  by  morning.  A  period  of  invasion 
lasting  36  or  48  hours  and  even  longer  is  exceptionally  observed  (Fig. 
51).  In  very  mild  cases  there  may  be  no  prodromes  whatever  or  none 
discovered. 


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Fig.  51.  Fig.  52. 

Fig.  51. — Scarlatina.     Average  Case  Except  for  Prolonged  Invasion,  with  Rash 

ON  THE  3d  Day. 
Helen  S.,  aged  2  years.     Nov.  19,  vomited,  fever;  Nov.  20,  no  complaint,  throat  very 
bright-red,  suspiciously  like  scarlatina;  Nov.  21,  rash  appearing,  vomited;  Nov.  22,  general 
condition  excellent,  rash  typical,  abundant,  throat  less  red;  Nov.  23,  rash  fading,  tongue  red 
at  tip,  rash  nearly  gone. 

Fig.  52. — Scarlatina.  Average  Case. 
Andreas  L.,  aged  8j^  years.  May  21,  nausea  in  evening,  fever,  sore  throat;  May  22, 
vomiting,  diarrhea,  secretion  in  tonsillar  crypts,  eruption  on  body;  May  23,  sore  throat, 
restlessness;  May  24,  eruption  very  abundant;  May  25,  eruption  duskier,  tongue  entirely 
denuded;  May  27,  eruption  fading,  throat  and  tongue  sore;  May  29,  sore  throat  no  longer 
complained  of. 

Period  of  Eruption. — The  Rash. — The  termination  of  the  period  of  inva- 
sion is  marked  by  the  appearance  of  the  rash  on  the  skin.  This  develops 
first  on  the  neck  and  upper  portion  of  the  chest;  thence  spreading  rapidly 
to  the  rest  of  the  trunk,  the  arms,  and  finally  the  lower  extremities.  Gen- 
erally the  face  is  little  or  not  at  all  involved,  the  forehead  and  especially 
the  circle  about  the  mouth  standing  out  prominently  of  a  pale  white 
color  in  contrast  with  the  rest  of  the  body;  the  cheeks  being  flushed,  but 
not  the  seat  of  a  truly  punctate  eruption.  In  some  cases,  however,  there 
is  an  extensive  development  of  eruption  on  the  face.  Viewed  superfi- 
cially the  rash  seems  to  be  of  a  uniformly  red  color,  but  careful  inspection 
shows  it  to  consist  of  very  minute,  closely  packed  red  points  situated  on 
a  white  base.     Later  the  red  hue  of  the  punctae  grows  duskier  while  the 


SCARLET  FEVER.     SCARLATINA 


315 


white  base  takes  on  a  shade  of  red  as  well.  Though  now  more  con- 
fluent the  punctate  character  can  still  always  be  discovered.  The  erup- 
tion generally  has  spread  to  its  full  extent  in  24  hours  and  often  less. 
Sometimes,  however,  2  or  3  days  are  required  for  this.  Its  greatest  inten- 
sity of  color  may  also  be  reached  within  24  hours,  but  is  not  generally 
attained  for  2  or  3  days.  Where  the  integument  is  softest  and  finest  the 
eruption  is  generally  especially  intense  and  most  confluent.  The  skin 
is  now  hot,  dry  and  somewhat  swollen,  the  swelling  being  frequently 
particularly  marked  on  the  hands  and  feet.  It  often  feels  slightly  rough 
to  the  hand  rubbed  over  it.  Decided  itching  is  common.  Drawing  the 
fingernail  over  the  red  skin  leaves  for  a  moment  a  strikingly  white  line. 
This  though  very  suggestive  is  not  absolutely  characteristic. 

The  rash  maintains  its  intensity  for  from  1  to  3  days  and  then  fades 
rapidly,  following  the  order  of  its  appearance.  The  total  duration  of 
the  eruption  is  extremely  variable.  An  average  may  be  said  to  be  from 
3  to  7  days. 


Fig.  5.3. — Scarlet  Fever. 
Blotchy  rash  suggesting  measles.     {Froyn  a  phofograph.) 


Normal  Variations  of  the  Eruption. — A  number  of  variations  occur  in 
the  eruption  within  the  limits  of  the  typical  case.  The  color  varies 
through  many  shades  of  red,  from  a  pale  rose  to  that  of  a  boiled  lobster, 
or  to  a  deep  red  with  a  slightly  brownish  or  bluish  tint.  When  the  erup- 
tion is  not  very  extensive  it  may  appear  in  smaller  or  larger  blotches 
in  some  part  of  the  body  leaving  other  parts,  especially  areas  on  the 
extremities,  entirely  free  (Scarlatina  variegata).  Sometimes  it  is  macu- 
lar in  some  portions  and  here  strikingly  suggests  measles  (Fig.  53).  In 
many  cases  the  skin  is  uiuisually  rough,  due  to  the  presence  of  nmch 
infiltration  in  the  minute  red  punctai  {Scarlatina  papulosa),  while  in  a 
large  number  there  is  a  greater  or  less  development  of  miliary  vesicles 
{Scarlatina  miliaris).  These  vesicles  may  occur  in  any  part  of  the  body. 
I  have  seen  them  so  abundant  that  the  scarlatinal  color  of  the  underlying 
skin  was  almost  totally  concealed'  and  the  diagnosis  made  difficult.  As  a 
rule,  however,  they  an^  few  in  number.  Their  occurrence  docs  not 
appear  to  me  to  bear  any  relationshij:)  to  the  intensity  of  the  ordinary 
scarlatinal  rash,  the  amount  of  desquamation,  or  the  severity'  of  the  case. 

'  Jacobi's  Festschrift,  1900,  1S2. 


316  THE  DISEASES  OF  CHILDREN 

In  rare  cases  the  vesicles  may  coalesce  to  a  considerable  extent,  forming 
small  blebs  (Scarlatina  pemphigoides). 

In  the  so-called  Surgical  Scarlet  Fever  the  rash  develops  sometimes 
first  in  the  neighborhood  of  a  wound,  and  thence  spreads  over  the  body,  or 
appears  in  the  ordinary  sequence  very  soon  after  the  receiving  of  a  wound, 
it  being  supposed  that  the  infection  gained  entrance  through  this.  The 
symptoms  do  not  differ  materially  from  those  of  the  disease  as  usually 
seen.  A  large  number  of  cases  are  described  in  medical  literature  which 
would  appear  properly  to  belong  in  this  category;  yet  very  many  others 
which  have  been  called  by  this  name  are  certainly  rather  instances  of 
septic  erythema.  There  is  considerable  doubt  whether  surgical  scarlet 
fever  exists  as  an  entity,  or  is  other  than  the  mere  coincidental  occur- 
rence of  the  disease  in  a  surgical  case. 

Retrocession  of  the  Eruption. — It  happens  oftent  hat  the  rash  soon 
after  its  appearance  suddenly  fades,  or,  as  it  is  commonly  called,  has 
''struck  in,"  the  other  symptoms  persisting  or  growing  worse.  This 
disappearance  is  often  the  result  of  a  feeble  action  of  the  heart.  It  is 
not  the  cause  of  unfavorable  symptoms,  but  the  accompaniment  of  them. 

Other  Symptoms  of  the  Stage  of  Eruption. — The  eruption  of  the  mucous 
membrane  of  the  mouth  and  throat  (enanthem)  is  reaching  its  height' 
when  that  of  the  skin  begins  to  appear.  The  intense  redness  of  the 
mucous  membrane  persists,  and  the  tonsils,  if  not  already  affected, 
generally  exhibit  lacunae  filled  with  secretion,  while  swallowing  is  pain- 
ful. The  tongue  begins  to  lose  its  white  coating,  and  by  the  3d  to  the 
5th  day  of  the  disease  has  become  entirely  denuded,  bright-red  and  with 
the  fungiform  papillse  swollen  and  prominent.  The  result  is  the  "straw- 
berry" or  ''raspberry"  tongue.  These  titles  have  often  been  misapplied 
to  the  condition  seen  during  invasion  and  in  many  other  diseases,  where 
the  red  papillae,  especially  on  the  edges  and  tip,  show  prominently  through 
the  white  coating.  In  many  cases  the  tongue  never  becomes  denuded 
throughout,  yet  the  enlargement  of  the  papillae,  at  least  of  its  tip  and 
edges,  is  claimed  by  McCollum^  to  be  invariably  present  and  to  con- 
stitute a  valuable  diagnostic  sign  in  cases  with  doubtful  or  absent  erup- 
tion. In  typical  cases  the  throat  improves  as  the  cutaneous  rash  and 
the  other  symptoms  abate.  By  the  7th  or  8th  day  of  the  disease  the 
normal  appearance  of  the  tongue  is  nearly  restored.  Close  examination, 
however,  will  show  a  persistence  of  some  degree  of  redness  and  swelling 
of  the  papilhe  at  the  edges  and  tip  of  the  organ  after  other  symptoms  of 
the  stage  of  eruption  have  entirely  disappeared.  The  nose  often  ex- 
hibits a  mucopurulent  discharge.  The  lymphatic  glands  of  the  superfices 
of  the  body  are  found  swollen,  those  of  the  neck,  groins  and  axillae  and 
those  below  the  body  of  the  jaw,  being  most  noticeably  so.  The  spleen 
is  often  palpable.  The  temperature  (Fig.  52)  is  subject  to  great  variations, 
and  no  typical  curve  exists.  As  a  rule  it  reaches  its  height  from  the  2d 
to  the  3d  day  and  continues  at  102°  to  104°F.  (38.9°  tg  40°C.)  with  little 
variation  between  morning  and  evening,  its  elevation  being  generally  in 
proportion  to  the  severity  of  the  attack.  It  begins  to  diminish  as  the 
eruption  fades,  falling  by  lysis,  and  reaching  normal  about  the  9th  or 
10th  day.  Very  often  the  elevation  of  temperature  lasts  a  much  shorter 
time  than  this.  The  pulse  is  rapid,  often  out  of  proportion  to  the  eleva- 
tion of  temperature.  This  is  generally  considered  one  of  the  character- 
istics of  the  disease.     The  blood-pressure  is  sometimes  reduced  (Rolles- 

1  Boston  City  Hospital  Reports,  1899. 


SCARLET  FEVER.     SCARLATINA  317 

ton)^  but  its  condition  possesses  little  practical  value  unless  nephritis 
occurs.  The  bowels  are  usually  not  disturbed.  There  is  thirst  and  loss 
of  appetite.  Vomiting  is  not  common  during  the  eruptive  stage.  Slight 
delirium  may  develop  during  the  height  of  the  fever.  Either  som- 
nolence or  restlessness  may  be  present. 

The  urine  is  high-colored  and  diminished  in  amount  and,  if  the  tem- 
perature is  high,  may  exhibit  febrile  albuminuria  with  cylindroids  and 
possibly  a  few  hyaline  casts;  but  blood-cells  and  granular  casts  do  not 
occur  unless  a  complicating  nephritis  develops.  Woody  and  Kolmer^ 
found  the  diazo-reaction  present  in  8.53  per  cent,  of  375  cases  examined. 
Urobilin  is  found  in  the  majority  of  instances  (Rach  and  Reuss;^ 
Gromski).* 

The  blood  shows  a  moderate  diminution  in  the  number  of  red  blood- 
cells  and  of  hemoglobin.  The  original  percentages  are  restored  after 
several  weeks.  According  to  Tileston  and  Locke^  a  hyperleucocytosis 
begins  from  the  2d  to  the  8th  day  reaching  from  18,000  to  40,000  per 
c.mm.  This  falls  gradually  and  reaches  normal  at  the  end  of  from  3  to 
6  weeks.  The  polymorphonuclear  cells  are  increased  absolutely  and 
relatively  during  the  stages  of  invasion  and  eruption,  reaching  85  to  90 
per  cent.,  and  decrease  to  normal  with  the  disappearance  of  the  leuco- 
cytosis.  The  mononuclear  cells  are  at  first  diminished,  sometimes  to 
Bven  4  or  5  per  cent.  The  eosinophiles  nearly  or  quite  disappear,  but 
rise  above  normal  with  defervescence  and  continue  so  into  convalescence. 
These  observations  confirm  for  the  most  part  the  earlier  studies  of 
Kotschenkow,^  Saquepee,^  Bowie, ^  and  others.  lodophiha  is  reported  bj^ 
Neutra^  and  Magi.  ^^  Great  interest  in  recent  years  has  attached  to  the  dis- 
covery by  Dohle^^  of  certain  "inclusion  bodies"  constantly  found  in  the 
polymorphonuclear  leucocytes  of  the  blood  in  scarlet  fever,  as  well  as  in 
the  internal  organs  and  lymphatic  glands  in  fatal  cases.  Except  in  fatal 
toxic  cases  they  are  always  present  up  to  the  4th  day.  They  were  at 
first  supposed  to  be  microorganisms  and  believed  to  be  the  cause  of  the 
disease;  but  this  view  has  been  abandoned,  and  their  nature  is  not  known. 
Their  absence  is  an  indication  that  the  condition  is  other  than  scarlet 
fever;  but  their  presence  is  not  specific,  since  they  have  been  shown  to 
occur,  although  in  smaller  numbers,  in  diphtheria,  measles,  lacunar 
tonsillitis  and  sepsis. 

Period  of  Desquamation. — As  other  symptoms  abate  and  the  eruption 
fades  the  skin  is  left  dry  and  rough  and  desquamation  then  begins, 
starting  in  the  localities  first  invaded  by  the  rash.  Spealdng  very  gen- 
erally only,  the  process  may  be  said  to  commence  at  the  end  of  the  1st 
week  of  the  disease.  In  many  cases  it  is  earlier,  and  in  some  nuich  later. 
The  scaling  is  of  two  forms.  The  first  is  a  branny  desquamation,  some- 
what similar  to  that  seen  in  measles,  and  occurs  on  the  head,  neck  and 
upper  portion  of  the  trunk.     Upon  the  hands  and  feet  there  is  a  very 

1  Rolleston,  Brit.  Jour.  Child.  Dis.,  1912,  IX,  444. 

2  Arch,  of  Ped.,  1912,  XXIX,  .Ian. 

3  Jahrb.  f.  Kinderh.,  1910,  LXXII,  422. 

*  Przegl.  pedyat.     Kef.  Monatssohr.  f.  Kinderh.,  Rcfcrat.,  1914,  XIII,  423. 

5  Journ.  of  Infect.  Dis.,  190.5,  II,  375 

»  Wratch,  1891,  No.  41.     Kef.  J.-ilirb.  f.  Ivinderh.,  1893,  XXXVI,  409. 

^  Arch,  de  rn6d.  experiment.,  1902,  XIV,  101. 

8  Journ.  of  Path,  and  Bact.,  1902,  VIII,  82. 

»  Zeitschr.  f.  Heilk.,  19()(),  XXVII,  433. 
"  Gaz.  desli  Osped.,  1908,  XXIX,  433. 
"  Centralbl.  f.  Bakt.  u.  Parasit.,  1892,  XII,  909. 


318 


THE  DISEASES  OF  CHILDREN 


Fig.  54. — Scarlet  Fever. 
Well-marked  desquamation  upon  the  dorsum  of  the  hands  and  fingers,  showing  the 
lamellar  peeling.      {Welch  and  Schamberg,  Acute  Contagious  Diseases,  1905,  377.) 


Fig.  55. — Scakllt  Ti-vi^u  wuu  Unusually  Sevekp:  Dioscjuamation. 
The  enlarging  scaling  rings  are  well  shown.     (Welch  and  Schamberg,  Acute  Co7itagious 
Diseases,  1905,  376.) 


SCARLET  FEVER.     SCARLATINA      .  319 

characteristic  lamellar  peeling,  the  dead  skin  coming  off  in  larger  or 
smaller  strips  (Fig.  54),  leaving  a  sharp  contrast  between  the  pink  new 
skin  exposed  and  the  remaining  old  grej'ish-white  skin.  It  begins 
here  often  at  the  tips  of  the  fingers  and  toes  and  especially  about  the  roots 
of  the  nails.  Occasionally  the  skin  is  shed  from  the  hands  and  feet  in 
the  form  of  true  casts.  The  desquamation  of  the  hands  and  feet  is  so 
characteristic  that  it  is  often  possible  to  make  the  diagnosis  on  this 
appearance  alone  in  cases  not  seen  earlier  in  the  attack.  On  the  rest  of 
the  body  and  especially  well  marked  on  the  trunk  the  branny  desquama- 
tion begins  as  a  small  white  scale  which  separates,  leaving  a  pin-hole-like 
opening  to  the  new  skin  beneath.  The  skin  surrounding  this  gradually 
peels  off,  enlarging  the  pin-holes  to  wider  circles  which  finally  fuse 
(Fig.  55). 

In  some  instances  the  two  forms  may  be  combined  to  a  large  extent 
throughout  the  body,  except  on  the  hands  and  feet  where  only  the  lamel- 
lar form  occurs.  Very  frequently  desquamation  is  absent  or  difficult 
to  discover.  This  is  especially  true  if  the  body  has  been  bathed  or  oiled 
often.  The  scaling  continues  for  from  10  days  or  less  up  to  2  or  3  weeks. 
It  begins  last  and  continues  longest  on  the  hands  and  feet,  and  here  4 
or  even  7  or  8  weeks  may  not  see  it  completed.  The  average  day  of  the 
disease  on  which  the  desquamation  ceased  in  91  cases  in  the  Hospital 
for  Scarlet  Fever  and  Diphtheria  of  New  York  (1901)  was  the  47th.  ^ 
Often  it  may  not  have  commenced  on  the  hands  and  feet  by  the  time  it  is 
nearly  or  quite  over  on  the  rest  of  the  body.  Not  infrequently  after 
scaling  has  apparently  ceased  it  recommences,  and  this  process  may  be 
repeated  several  times.  The  duration  and  degree  of  desquamation 
usually  bears  some,  but  no  necessary,  relationship  to  the  severity  of  the 
case  and  intensity  of  the  eruption.  There  is  reason  to  believe  that  it  is 
even  possible  for  desquamation  to  occur  in  regions  where  there  has  been 
no  rash  whatever;  consequently  other  causes  than  the  mere  hyperemia  of 
the  skin  would  appear  to  be  active  agents  in  producing  it.  Nevertheless, 
as  a  rule,  an  intense  eruption  is  attended  by  abundant  desquamation,  and 
vice  versa. 

Desquamation  affects  other  epithelial  structures  as  well.  The  nails 
exhibit  it  to  a  greater  or  less  extent  and  the  hair  becomes  brittle  and  falls. 
The  teeth,  too,  are  sometimes  affected  by  the  disease  and  exhibit  erosions. 
In  cases  where  miliaria  has  ])een  extensive  a  fine  branny  scaling  may  take 
place  early.  This  is  not  to  be  confounded  with  the  true  scarlatinal 
desquamation  which  occurs  later.  During  the  stage  of  desquamation 
all  other  symptoms  are  absent  in  normal  cases  and  the  patient  feels  well 

Atypical  Types  of  Scarlet  Fever.  (Mild;  Severe;  Anginose 
Malignant;  Hemorrhagic). — Different  classifications  of  the  varieties  of 
scarlet  fever  have  been  made.  There  are  no  strict  boundaries  separating 
one  from  another,  l)ut  a  convenient  division  is  the  following: 

Mild  Forms. — The  attack  may  be  unusually  mild  throughout,  or 
some  of  the  symptoms  may  be  absent  entirely.  There  may  be  a  sudden 
onset  with  fever,  which  may  disappear  completely  in  the  course  of  a  very 
short  time.  The  eruption  may  be  so  slightly  developed  that  its  nature 
is  questionable,  or  it  may  be  so  evanescent  or  limited  to  so  small  an  area 
that  it  is  entirely  overlooked.  The  throat  may  have  exhibited  only  slight 
traces  of  redness,  and  the  tongue  may  never  have  shown  a  decidedly 
characteristic  appearance.     The  child  may  seem  little,  if  at  all,  ill.     In 

1  Report  Hospital  Scarlet  Fever  and  Diphtlicria  I'jitit'iits,  11K)1,  22. 


320 


THE  DISEASES  OF  CHILDREN 


many  of  these  cases  it  is  only  on  the  occurrence  later  of  desquamation, 
or  perhaps  of  nephritis  as  a  sequel,  that  a  tardy  diagnosis  is  made.  Dif- 
ferent varieties  of  the  mild  form  are  seen: 

(a)  In  some  cases  the  diagnosis  from  the  beginning  is  unquestionable, 
but  the  disease  runs  a  very  short  and  mild  course  (Fig.  57),  and  the  whole 
process  is  over  in  from  2  to  4  days,  except  perhaps  for  the  desquamation 
later,  although  even  this  is  often  absent  (Abortive  scarlet  fever) . 

(h)  There  seems  to  be  no  doubt  that  the 
eruption  need  not  develop  at  all  (Scarlatina 
sine  eruptione) .  This  is  especially  often  seen  in 
those  persons  associated  with  scarlet  fever  cases 
who  have  had  the  disease  before.  Such  indi- 
viduals exhibit  only  some  fever  and  an  angina 
with  more  or  less  involvement  of  the  tongue. 
The  condition  has  been  denominated  "scarlatinal 
sore  throat.'^  Such  cases  are  as  capable  as  others 
of  spreading  the  disease. 

(c)  Another  mild  form  shows  an  entire  or 
nearly  complete  absence  of  fever  (Scarlatina 
afebrilis) .  Such  cases  are  generally  accompanied 
by  a  very  meagre  development  of  the  rash,  and 
of  other  symptoms.  Sometimes,  however,  the 
rash  is  very  typical,  yet  with  a  temperature 
normal  or  rarely  exceeding  100°F.  (37.8°C.). 
1  have  seen  this  attended  by  an  absolutely 
characteristic  tongue  and  by  subsequent 
nephritis,  making  the  diagnosis  certain  (Figs. 
58  and  59). 

(d)  In  still  another  form  inflammation  of 
the  pharynx  is  absent  or  represented  only  by  a 
very  slight  redness  of  the  pillars  without  swelling 
of  the  tonsils  (Scarlatina  sine  angina). 

The  term  ''rudimentary  form"  is  sometimes 
used  to  denote  many  of  these  mild  cases  with 
some  symptoms  undeveloped.  It  is  however 
equally  applicable  to  some  of  the  severest 
atypical  forms  in  which  only  certain  of  the 
symptoms  of  the  disease  are  present  although 
these  are  severe.  The  title  is  therefore  confusing. 
Severe  Forms. — (a)  In  the  ordinary  severe 
form  as  most  commonly  seen  all  the  symptoms 
of  the  disease  may  be  present  to  an  unusual  degree. 
The  onset  is  rapid;  there  may  be  violent  vomiting;  the  eruption  is  very 
intense  and  widespread  and  soon  becomes  dark  red  in  tint;  the  tempera- 
ture is  persistently  high;  the  glands  of  the  neck  are  much  swollen;  the 
inflammation  of  the  throat  and  mouth  is  severe;  delirium  is  present;  there 
is  great  restlessness;  convulsions  may  occur  and  coma  supervene;  the 
pulse  is  rapid  and  weak;  prostration  is  great  and  dyspnea  may  be  marked. 
Death  may  take  place  in  a  few  days,  or  the  attack  may  last  for  weeks, 
the  patient  convalescing  very  slowly,  if  at  all.  The  severity  of  the  attack 
may  appear  to  be  the  direct  result  of  the  scarlatinal  poison,  or  the  symp- 
toms may  be  the  varying  ones  of  sepsis. 

The  severe  forms  of  the  disease  show  numerous  variations  from  this 
type.     These  are  not  sharply  differentiated  from  each  other.     Thus: 


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Fig.'  57. — Scarlatina; 
Abortive  Form. 
Weightman  F.,  aged  9 
years.  Apr.  23,  vomited; 
Apr.  24,  rash  appearing; 
Apr.  25,  rash  at  height,  well 
developed;  Apr.  26,  tongue 
beginning  to  peel;  May  13, 
desquamation  on  hands  and 
feet  discovered;  none  found 
elsewhere. 


SCARLET  FEVER.     SCARLATINA 


321 


(6)  The  severity  may  depend,  perhaps,  on  the  special  prominence 
of  one  or  a  few  symptoms  or  complications,  the  attack  being  "rudimen- 
tary" so  far  as  the  complete  development  of  the  disease  is  concerned. 

(c)  There  occur  differences  in  the  development  of  the  eruption.  In 
many  severe  cases  instead  of  being  unusualh'  well  marked  it  is  faint, 
localized,  blotchy,  and  tends  constantly  to  fade. 

{d)  In  one  variety  the  disease  is  characterized  not  so  much  by 
development  of  any  localized  symptoms  as  by  long  continuance  of  the 
fever  without  discoverable  cause,  there  occurring  such  nervous  symptoms 


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Fig.  58. — Scarlatina  Afebrilis. 
Henry  P.,  aged  9  years.     Typical  rash,  slight  redness  of  throat,  moderate  development 
of  strawberry  tongue.     Later  slight  scarlatinal  desquamation  and  albuminuria  with  casts. 

Fig.  59. — Scarlatina  Afebrilis. 
Frank  M.,  aged  3  years.     Recovering  from  typhoid  fever.     Apr.  3,  typical  miliary 
scarlatinal  eruption,  tonsils  red,  secretion  in  follicles,  tongue  beginning  to  peel;  Apr.  5, 
rash  still  very  bright,  miliaria  drying;  Apr.  8,  profuse  branny  desquamation  from  the 
miliaria;  Apr.  11,  typical  scarlatinal  desquamation. 

as  headache,  delirium,  apathy,  etc.,  or  stupor  and  the  symptoms  in  gen- 
eral of  the  typhoid  state,  on  account  of  which  the  title  Scarlatina 
typhosa  has  been  applied  to  it. 

(e)  A  fairh^  characteristic  variety,  dependent  in  reality  on  a  complica- 
tion, yet  so  common  that  it  may  well  be  dcscril)ed  here,  as  is  the  anginose 
form  (Scarlatina  amjinosa)  (Fig.  60).  In  this  the  disease  usually  starts  as 
an  ordinary  case  and  it  is  not  until  the  3d  or  4th  day  or  later  that  the 
characteristic  symptoms  appear.  Sometimes  the  fever  lias  commenced 
to  fall,  and  the  child  seems  about  to  convalesce,  when,  with  an  increase 
of  temperature,  the  anginose  symptoms  begin.     Pseudonicmbrane,  the 

21 


322 


THE  DISEASES  OF  CHILDREN 


result  probably  of  invasion  by  streptococci,  then  develops  on  the  tonsils 
and  may  spread  to  the  uvula  and  pillars,  the  posterior  wall  of  the  pharynx, 
the  nose,  and  occasionally  the  mouth.  The  submaxillary  lymphatic 
glands  become  very  much  swollen.  The  appearance  may  be  that  typical 
of  faucial  diphtheria,  and  inasmuch  as  scarlet  fever  is  so  often  complicated 
by  a  true  diphtheritic  invasion,  the  diagnosis  can  only  be  made  by  a 
bacteriological  examination.  In  severe  cases  fever  remains  high,  the 
pulse  becomes  weak,  nervous  symptoms  are  marked,  and  there  develops 
a  profound  general  septic  state  with  great  prostration.  In  other  cases 
the  lesions  may  go  on  to  necrosis,  and  be  attended  by  extensive  sloughing 
with  abscesses. 


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Minnie  L.,  aged  7  years.  May  30,  vomiting  in  the  evening  and  night;  May  31,  rash 
appeared,  throat  inflamed;  June  2,  throat  more  inflamed;  June  5,  tongue  peeling;  June  7, 
rash  disappearing,  inflammation  of  throat  has  increased,  tonsils  now  thickly  covered  by 
white  exudate;  June  12,  throat  still  inflamed,  but  better;  pneumonia  of  low  grade  developed. 


Even  in  the  milder  cases  of  anginose  scarlet  fever  the  local  condition 
lasts  for  a  week,  more  or  less,  and  decidedly  prolongs  the  attack  while  it 
adds  greatly  to  the  discomfort  and  debility  of  the  patient  and  to  the 
danger  of  involvement  of  the  ears. 

(/)  One  of  the  severe  types  of  scarlet  fever  is  the  malignant  or  cere- 
bral variety  {Scarlatina  maligna).  The  onset  of  this  form  is  extremely 
sudden  with  a  preponderance  of  nervous  symptoms,  the  child  appearing 
to  suffer  from  an  over-powering  intoxication.  There  occur  repeated  vomit- 
ing, intense  headache,  very  high  fever,  and  restlessness  and  delirium 
soon  passing  into  coma,  perhaps  with  convulsions.  The  urine  may  be 
suppressed,  the  rash  may  be  very  intense,  dark-red  and  often  of  a  purplish 
cast  from  the  presence  of  numerous  petechise.     Sometimes  there  are 


SCARLET  FEVER.     SCARLATINA 


323 


hematuria,  purpura,  epistaxis,  and  hemorrhages  from  other  parts  of  the 
body  (Fig.  61)  (Scarlatina  hemorrhagica).  In  other  cases  the  rash  is 
but  Httle  developed,  or  even  entirelj^  absent.  The  inflammation  of  the 
throat  likewise  may  not  be  present.  In  such  cases  there  may  be  nothing 
on  which  to  base  a  diagnosis,  unless  the  case  occur  in  connection  with 
others.  •  Death  may  take  place  in  a  few  days,  or  even  in  a  few  hours.  In 
still  other  instances  the  disease  may  begin  in  the 
ordinary  manner  and  the  evidence  of  malignancy 
does  not  appear  until  the  2d  or  3d  day. 

Complications  and  Sequels. — Numerous 
disordered  conditions  ma}^  accompany  or  follow 
scarlet  fever,  but  not  many  of  these  are  of  frequent 
occurrence:  In  153,607  cases  reported  b}^  the 
Metropohtan  Asylums  Board  from  1900  to  1909 
(Goodall)^  the  incidence  of  the  more  important 
complications  equalled:  otitis  13.1  per  cent., 
adenitis  8.1  per  cent.,  nephritis  other  than  simple 
albuminuria  4.6  per  cent.,  and  arthritis  3.5  per  cent. 

Throat  and  Nose. — Different  varieties  of  faucial 
involvement  have  been  described,  chief  among 
them  being  the  erythematous,  pseudomembranous, 
and  gangrenous  forms.  There  exists,  however, 
no  sharp  boundary  line  and  they  shade  into  each 
other.  The  erj^thematous  throat,  combined  often 
with  some  engorgement  of  the  tonsillar  follicles 
with  secretion,  is  always  seen  in  typically  nor- 
mal cases.  It  is  only  when  the  process  goes  on  to 
the  development  of  a  pseudomembrane,  perhaps 
followed  by  extensive  necrotic  changes,  that  the 
condition  can  be  considered  as  a  complication. 
This  occurs  so  often  that  it  characterizes  one  of 
the  variant  forms  of  the  disease.  There  may  even 
be  produced  a  condition  which  is  clinically  in- 
distinguishable from  that  seen  in  diphtheria.  My 
own  experience  has  been  that  of  others;  that 
severe  and  even  finally  fatal  cases  of  this  condition 
may  occur  in  which  it  is  doubtful  whether  a  scar- 
latinal rash  has  ever  been  present.  The  nose  is 
often  involved  by  the  pseudomembrane,  and  an 
irritating  thin  dischai'ge  takes  place  from  it  which 
excoriates  the  upper  lip.  Nasal  respiration  may 
become  impossible.  Only  occasionally  is  the  lar3^nx 
invaded.  The  symptoms  attending  this  inflamma- 
tion of  the  nose  and  thioat  have  already  been 
described  (p.  321). 

Ears. — Otitis  media  is  one  of  the  fre(]uent  complications.  It  is 
especially  prone  to  develop  when  the  inflammation  of  the  throat  has  been 
severe,  altliough  by  no  means  only  then,  the  disease  spreading  along  the 
Eustachian  tube  to  the  ear.  Younger  children  are  most  disi)oso(l  to  it. 
The  proportion  of  cases  developing  it  varies  greatly  with  the  epiilcinic. 
Caiger^  reports  suppurating  otitis  media  in  11.05  per  cent,  of  4015  cases; 


0.-0,-0.,- 

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Fig.  61. — Malignant 
Sc.'VRLET  Fever. 
Domenick  S.,  aged 
2  years.  Jan.  2,  vomit- 
ing, dyspnea  and  irregu- 
lar respiration;  Jan.  3, 
red,  uncharacteristic 
eruption,  throat  red, 
tonsils     enlarged;    Jan. 

4,  widespread,  abundant 
petechial  eruption  com- 
bined with  the  scarla- 
tinal rash,  coma,  res- 
piration rapid  and 
dyspncic,  pulse  rapid, 
tonsillar    exudate;  Jan. 

5,  death  at  1  a.  m. 


'  C;;irro(l,  Batten  aiul  Thursfiold,  Diseases  of  Children,  1913,  1009. 
-  AUbutt's  System  of  Med.,  1.S97,  III,  loO. 


324  THE  DISEASES  OF  CHILDREN 

Pugh^  in  15  per  cent,  of  11,000  eases,  and  Borden^in  11  per  cent,  of  2232 
cases  and  45-4  autopsies.  Baum^  found  it  in  1.07  per  cent,  of  628  cases 
although  some  pain  in  the  ears  was  experienced  in  about  35  per  cent. 
Both  ears  are  generally  affected.  The  greater  frequency  of  perforative 
otitis  in  the  severe  cases  of  scarlet  fever  is  shown  by  the  analysis  of 
Holmgren^  of  9590  subjects  with  this  disease.  In  511  fatal  cases  per- 
foration had  occurred  in  30  per  cent. 

Otitis  may  terminate  in  complete  recovery,  generally  after  perforation, 
but  many  instances  of  some  degree  of  permanent  deafness  owe  their 
origin  to  a  scarlatinal  otitis.  This  occurred  in  21.17  per  cent,  of  Burk- 
hardt-Meiringen's^  85  cases  of  deafness.  In  older  children  with  normal 
cerebral  condition  the  otitis  is  generally  accompanied  by  severe  earache 
and  deafness.  In  those,  however,  in  which  mental  dullness  exists,  and 
in  all  younger  patients,  the  symptoms  are  very  obscure.  Sometimes 
a  return  of  fever  with  fretfulness  is  the  only  indication  until  spontaneous 
rupture  of  the  drum-membrane  occurs.  The  presence  of  tenderness 
over  the  region  in  front  of  the  tragus  or  behind  the  ear  is  often  the  chief 
symptom  unless  the  drum-membrane  be  frequently  examined.  The 
greatest  watchfulness  of  these  cases  is  therefore  necessary.  One  of  the 
chief  dangers  is  the  development  of  mastoid  disease  with  subsequent 
purulent  meningitis  and  septic  symptoms.  This  may  come  on  without 
the  previous  existence  of  otitis  having  been  recognized  at  all.  Even 
in  cases  where  perforation  of  the  drum-membrane  has  occurred  the 
presence  of  a  free  flow  of  pus  does  not  insure  against  the  development  of 
mastoiditis. 

Otitis  may  occur  either  at  the  beginning  of  the  disease  or  oftener  as  a 
sequel  after  desquamation  has  commenced  or  convalescence  been  entirely 
established. 

Cervical  Adenitis. — The  lymphatic  glands  of  the  neck  are  always 
somewhat  enlarged  in  all  cases  where  sore  throat  is  a  prominent  symptom. 
Sometimes  they  become  greatly  so,  and  may  go  in  to  the  formation  of 
abscess.  This  takes  place  oftenest  as  a  sequel  in  the  2d  week  or  later. 
It  is  attended  by  fever,  but  not  by  any  marked  septic  symptoms,  and 
is  relieved  by  spontaneous  opening  or  by  incision.  In  bad  cases  of  the 
anginose  form,  however,  the  engorgement  and  subsequent  necrosis  of 
the  lymphatic  glands  is  contemporaneous  with  the  angina.  The 
swelling  may  become  extreme  and  a  cellulitis  of  the  tissues  of  the  neck 
may  develop,  which  can  reach  such  an  extent  that  the  natural  depression 
beneath  the  jaw  is  everywhere  completely  obliterated.  The  head  is 
thrown  back,  and  respiration  may  be  much  interfered  with.  This  may 
go  on  to  the  formation  of  pus,  which  makes  its  way  either  toward  the 
surface  or  along  the  sheaths  of  the  muscles  or  the  great  vessels.  Very 
extensive  sloughing  may  take  place,  and  blood  vessels  may  be  perforated. 
The  attending  symptoms  are  always  of  a  gravely  septic  nature.  Adenitis 
of  a  degree  sufficient  to  be  called  a  comphcation  was  found  by  Schick® 
in  7.2  per  cent,  of  990  cases;  and  by  Caiger  and  Dudgeon^  in  11.4  per 
cent,  of  10,983  cases. 

1  Lancet,  1905,  I,  273. 

2  Boston  Med.  and  Surg.  Journ.,  1913,  CLXVIII,  221. 

3  Journ.  Amer.  Med.  Assoc,  1903,  ()(^t.  10,  90(5. 

^  Otolaryngologiska  Medelanden,  1912,  I,  1.  Ref.  Jahrb.  f.  Kinderh.,  1913, 
LXXVIII,  475. 

5  Volkmann's  Samml.  klin.  Vortr.  Chir.,  No.  54,  1489. 

6  Arch.  f.  Kinderh.,  1905,  XLIII,  459. 
'  Loc.  cit,  452. 


SCARLET  FEVER.     SCARLATINA 


325 


Arthritis  (Fig.  62).— This  may  often  complicate  or  follow  scarlet  fever, 
generally  in  those  past  early  childhood.  Heubner^  saw  it  in  8  per  cent,  of 
his  358  cases;  Ashby'-  in  2.4  per  cent,  of  500  cases;  Heiberg^  m  19.1 
per  cent,  of  1000  cases;  Baum"  in  3.7  per  cent,  of  628  cases,  and  Brade= 
in  6.9  per  cent,  of  868  cases.  In  the  majority  of  instances  it  is  a  synovitis 
{scarlatinal  rheumatism)  occm-ring  about  the  end  of  the  1st  week,  some- 
times earlier  or  later.  It  involves  especially  the  hands,  fingers  and>lbows, 
although  any  of  the  joints  may  be  affected.     The  attack  lasts  generally 


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Fig.  62. — Scarlet  Fevek  with  Temperature  Prolonged  by  Arthritis. 
Genctte  P.,  aged  5  years.     Apr.  20,  fever,  vomiting;  Apr.  21.  well-developed  eruption; 
Apr.  22,  a  few  white  spots  on  tonsils;  Apr.  23,  rash  at  maximum,  tongue  peeling;  Apr.  24, 
rash  fading;  Apr.  20,  multiple  arthritis,  involving  fingers,  elbows,  knees  and  ankles;  May 
5,  joints  improving. 

not  more  than  3  or  4  days.  It  is  a  mild  affection  characterized  by  pain 
and  with  generally  moderate  swelling  and  redness.  There  may,  however, 
be  nothing  visible  on  inspection  of  the  joints.  The  likelihood  of  its 
developing  bears  no  relationship  to  the  severity  of  the  scarlatinal  attack. 
It  is  probably  not  truly  rheumatic  in  nature,  although  cases  are  occa- 
sionally seen  in  which  true  rheumatism  and  scarlet  fever  appear  to 
be  combined. 

Another  less  frequent  form  of  arthritis  is  apparently  septic  in  nature 
and  goes  on  to  suppuration.  It  may  involve  one  or  more  of  the  larger 
joints,  and  possesses  a  graver  prognosis. 

Nephritis. — This  is  one  of  the  most  common  and  often  most  serious 
of  the  complications  or  sequels  of  scarlet  fever.     Some  writers  regard 

I  Dcutscho  Klinik,  1902,  VII,  280. 

■  Brit.  JNIcd.  .lourn.,  188:5,  II,  514. 

^  Zoitschr.  f.  UyK-  u  Infcotionskninkh.,  1010,  LXV,  237. 

^  Journ.  Amcr.  Med.  Assoc,  lOO:},  Oct.  10,  i)0(). 

"*  Inaug.  Dissert.  Leipzig,  1904.     Ilef.  Moiiatsschr.  f.  Kindcrh.,    1904,    HI,  6lb. 


326  THE  DISEASES  OF  CHILDREN 

a  degree  of  involvement  of  the  kidneys  as  one  of  the  constant  symptoms 
of  the  disease.  The  presence,  however,  of  shght  albuminuria,  perhaps 
with  cjdindroids  and  even  hyaline  casts,  as  often  seen  in  the  first  days 
of  an  attack  of  scarlet  fever  when  the  temperature  is  high,  is  what  is 
liable  to  occur  in  any  of  the  febrile  infectious  diseases,  and  cannot  properly 
be  looked  upon  as  evidence  of  nephritis.  In  the  severer  cases  of  scarlet 
fever,  however,  particularly  when  any  septic  process  is  present,  as  for 
instance  in  the  throat,  an  acute  diffuse  nephritis  frequently  develops 
during  the  height  of  the  disease.  It  is  seen  with  great  frequency  in  the 
malignant  cases.  The  nephritis  may  come  on  with  suddenness  and 
severity,  with  great  diminution  of  the  urinary  secretion  and  the  presence 
in  it  of  much  albumin  and  with  casts  and  blood.  The  symptoms  are 
those  of  uremia  rather  than  of  dropsy.  Convulsions  often  occur.  In 
cases  not  so  severe  there  may  be  no  special  symptoms,  or  those  present 
may  be  masked  by  the  graver  ones  of  the  scarlet  fever  itself. 

The  most  frequent  form  of  nephritis,  however,  is  that  denominated 
post-scarlatinal,  occurring  as  a  sequel.  This  develops  in  the  3d  or 
4th  week  after  the  onset  of  the  scarlet  fever,  and  is  just  as  liable  to  follow 
the  mildest  cases  as  any  others.  The  lesions  are  oftenest  those  of  a  glom- 
erular nephritis.  The  onset  may  be  sudden  with  widespread  dropsy  and 
with  the  very  scanty  secretion  of  a  smoky  or  coffee-colored  urine  con- 
taining much  albumin,  blood  cells,  granular  epithelium  and  very  numerous 
casts  of  different  forms.  Convulsions,  vomiting  and  other  uremic 
symptoms  may  develop.  Complete  anuria  may  last  for  a  time  (Northrup^ 
5  days;  recovery).  Death  may  follow  promptly,  or  there  may  be  a 
gradual  amelioration  of  the  symptoms,  the  urine  becoming  more  abundant 
and  of  lower  specific  gravity,  the  fever  lessening,  and  the  child  showing 
evidences  of  anemia.  In  the  majority  of  cases,  however,  the  symptoms 
are  much  less  severe  and  their  onset  often  insiduous.  There  may  be 
only  slight  edema,  especially  of  the  hands,  feet  and  eyelids;  a  moderate 
degree  of  fever,  irritability  and  restlessness;  and  but  a  small  amount  of 
albumin  in  the  urine  with  a  few  casts  of  different  sorts.  As  in  the  severer 
but  not  fatal  cases,  convalescence  is  slow,  the  albumin  and  casts  con- 
tinuing perhaps  for  months  and  finally  disappearing,  and  recovery  being 
complete  in  the  majority  of  instances.  There  is  noted  a  decided  tendency 
for  the  nephritis  to  relapse,  and  this  may  persist  for  many  months.  There 
have  been  instances  reported,  and  even  some  epidemics,  in  which  edema 
has  developed  subsequent  to  scarlet  fever  yet  without  any  evidence  in  the 
urine  of  an  inflammation  of  the  kidneys  (Quincke),'-  In  some  such  cases, 
however,  the  lesions  of  nephritis  have  been  foundfpost-mortem.  In  only 
a  few  instances  does  the  nephritis  become  chronic.  A  study  by  Rosen- 
feld  and  Schwitka  v.  Rechtenstamm^)  of  94  individuals  who  had  had 
acute  scarlatinal  nephritis  several  years  previously  failed  to  reveal  a  single 
instance  of  severe  chronic  nephritis  remaining. 

Nephritis  may,  of  course,  lead  to  other  complications,  such  as  cardiac 
hypertrophy  and  dilatation,  effusion  into  the  pleural  and  pericardial  sacs, 
and  the  like.  The  relative  frequency  of  the  occurrence  of  nephritis  in 
connection  with  scarlet  fever  varies  greatly  with  the  epidemic.  The 
views  of  writers  as  to  what -constitutes  the  evidence  of  nephritis  also  influ- 
ence the  statistics.     Ashby  and  Wright*  estimate  the  average  propor- 

1  Med.  Rec,  1910,  LXXVIII,  706. 

2  Berliner  klinische  Wochenschrift,  1882,  XIX,  57. 

3  Zeitschr.  f.  Kinderh.,  OriK-,  1912,  IV,  265. 
*  Diseases  of  Children,  1893,  247. 


SCARLET  FEVER.     SCARLATINA  327 

tion  of  patients  attacked  as  6  per  cent.  Caiger  and  Dudgeon'  give  4 
per  cent,  in  10,983  cases;  Royer^  7.76  per  cent,  of  756  cases.  Others 
have  given  higher  figures. 

The  causes  of  nephritis  in  scarlet  fever  are  not  certainly  known.  In 
the  cases  associated  with  septic  processes  some  pus-germ  is  probably 
the  active  agent.  In  those  developing  during  malignant  scarlet  fever  and 
in  the  post-scarlatinal  cases  it  is  probably  the  toxic  products  of  the  scarlet 
fever  germ,  whatever  this  may  be.  The  predisposing  influence  of  ex- 
ternal conditions  is  uncertain.  (Fuller  reference  to  the  pathology  and 
treatment  of  scarlatinal  nephritis  will  be  found  under  the  heading  of 
Nephritis). 

Circulatory  System. — Functional  transitory  disturbances  of  the  heart 
are  not  uncommon  during  scarlet  fever,  but  serious  lesions  directly  pro- 
duced by  the  disease  are  less  frequent.  Endocarditis  and  pericarditis 
occur  occasionally  as  the  result  of  a  complicating  nephritis  or  a  rheumatic 
synovitis,  or  as  one  of  other  septic  manifestations.  I  have  observed  very 
few  cases  in  which  chronic  valvular  disease  could  be  without  question 
attributed  to  an  antecedent  scarlatina.  Embolism  of  the  pulmonary 
or  other  arteries  has  been  observed.  Myocardial  degeneration  is  present 
to  some  extent  in  many  cases,  especially  if  these  are  severe  and  accom- 
panied by  high  fever.  If  considerable,  it  may  produce  acute  dilatation. 
Dilatation,  however,  and  especially  hypertrophy,  generally  depend  upon 
a  nephritis  and  are  sequels  rather  than  complications.  Hypertrophy 
the  result  of  this  cause  comes  on  rapidly  and  may  present  demonstrable 
physical  signs  even  within  a  week  from  the  onset  of  the  renal  inflamma- 
tion. PopischilP  believed  that  the  heart  is  often  characteristically  af- 
fected in  scarlet  fever,  there  being  a  splitting  of  the  first  sound  and  a  mur- 
mur suggesting  pericarditis;  these  depending  iipon  myocardial  changes. 
The  symptom  is  observed  especially  at  the  beginning  of  the  attack. 
Lederer  and  Stolte^  confirm  this  observation. 

Respiratory  System. — The  general  opinion  is  that  pulmonary  com- 
plications and  sequels  are  not  nearly  so  frequent  in  scarlet  fever  as  in 
some  other  diseases.  Hutinel,^  however,  found  that  about  }  3  of  the 
deaths  in  2500  cases  were  from  bronchopneumonia,  and  that  croupous 
pneumonia  and  pleurisy  also  were  frequent  complications  or  sequels.  The 
involvement  of  the  nasal  mucous  membrane  has  been  spoken  of  in  connec- 
tion with  the  throat.  Pseudo-membranous  laryngitis  not  associated 
with  the  germs  of  diphtheria  is  of  rare  occurrence.  Pleurisj^  with  effu- 
sion, often  purulent,  is  an  occasional  sequel.  Its  onset  is  frequently  very 
insidious  and  entirely  unsuspected.  Bronchitis  occasionally  develops. 
Bronchopneumonia  is  a  dangerous  complication,  usually  occurring  only 
in  association  with  nephritis.  Severe  septic  cases  of  scarlet  fever  quite 
commonl}'  exhil)it  bronchopneumonia  at  autopsy.  Croupous  jineunio- 
nia  is  generally  believed  to  be  uncommon  except  in  combination  with 
nephritis.  The  opinion  of  Hutinel  opposes  this.  Edema  of  the  lungs 
and  edema  of  the  glottis  occasionally  occur  as  a  result  of  disease  of  the 
kidneys. 

Gastrointestinal  Complications. — These  are  not,  as  a  rul(%  trouble- 
some.    Vomiting  is  very  common  at  the  beginning  of  the  attack,  and 

'  Loc.  cit.,  2.   45 

-•  Ponna.  Mod.  .Jourii.,  li)0G-7,  X,  286. 

3  Wicn.  klin.  Woclioiisclir.,  1<)()7,  XX,  1089. 

*  Juhrl).  f.  Kinderh.,  1911.  J.XXIV.  ;39.x 

*  Arcli.  de  m6d.  des  enf.,  lUlO,  XIX,  57. 


328  THE  DISEASES  OF  CHILDREN 

ulcerative  stomatitis  is  a  complication  occasionally  seen  in  j^oung  chil- 
dren. It  is  usually  mild,  but  sometimes  as  a  sequel  is  severe.  Diarrhea 
is  a  frequent  complication.  It  is  generally  of  a  catarrhal  nature,  but  may 
be  inflammatory.  In  some  cases  it  is  very  obstinate  and  debilitating. 
It  may  devcloji  during  the  height  of  the  disease,  or  be  one  of  the  earliest 
sjmiptoms  of  the  eruptive  stage.     Slight  icterus  is  very  common. 

Nervous  System. — Among  nervous  complications  and  sequels  are  es- 
pecially to  be  mentioned  repeated  convulsions.  At  the  onset  of  the  attack 
these  generally  have  little  significance,  but  later  they  are  suggestive  of 
uremia.  Meningitis  and  thrombosis  of  the  cerebral  veins  or  sinuses 
may  occur  as  sequels  depending  upon  an  otitis.  Occasionally  a  menin- 
gitis occurs  earlier  in  the  disease  and  independently  of  any  afi'ection  of 
the  ear.  Hemiplegia  has  been  known  to  follow  meningeal  hemorrhage 
or  be  caused  by  embolism  dependent  upon  an  endocarditis.  Paralj'sis 
has  also  been  seen  as  a  result  of  neuritis  or  of  disease  of  the  spinal  cord. 
Chorea  and  epilepsy  are  sequelae  occasionally  reported,  and  various 
psychoses  are  on  record.     Amaurosis  may  develop  as  a  result  of  nephritis. 

Cutaneous  Complications. — Urticaria  and  erythema  are  sometimes 
observed  after  the  disappearance  of  the  scarlatinal  eruption,  and  eczema, 
is  not  an  uncommon  sequel.  Rolleston^  found  herpes  facialis  27  times 
in  413  cases.  Sj'mmetrical  gangrene  is  an  occasional  complication. 
Silberstein-  added  1  case  to  13  others  collected  from  medical  hterature. 

Other  infectious  diseases  may  occur  in  combination  with  scarlet 
fever  or  as  sequels  to  it.  One  of  the  most  frequent  and  serious  combina- 
tions is  that  of  scarlet  fever  and  diphtheria,  the  latter  developing  generally 
in  a  patient  already  suffering  from  the  former.  It  is  more  prone  to  appear 
from  the  3d  to  the  6th  week  after  the  attack  of  scarlet  fever,  sometimes 
earlier  or  later.  Measles  and  scarlet  fever  have  often  occurred  together. 
Among  other  combinations  are  those  with  varicella,  variola,  pertussis, 
erysipelas,  typhoid  fever,  etc.  Either  disease  may  develop  first.  Tuber- 
culosis already  in  the  system  may  be  brought  into  activity  by  the  occur- 
rence of  scarlet  fever. 

Among  other  rarer  complications  or  sequels  which  have  been  reported 
may  be  mentioned  perichondritis  of  the  larynx;  esophagi tis;  necrotic 
inflammation  of  the  stomach;  gastric  hemorrhage;  optic  neuritis;  icterus; 
encephalitis;  periostitis;  peritonitis;  noma;  furunculosis;  vulvo-vaginitis; 
purpura;  myositis;  pemphigus;  and  glycosuria. 

Relapse. — Relapse  is  occasionally  seen,  but  is  rare.  McCollum^ 
found  it  4  times  in  1000  cases  (0.4  per  cent.)  and  Sloan'*  154  times  in  14,143 
cases  (1.8  per  cent.)  of  the  Hospitals  of  the  Metropolitan  Asylums  Board. 
It  consists  in  the  return  of  some  or  all  of  the  symptoms  after  the  disease 
is  apparently  over,  but  while  the  original  infection  is  doubtless  still  in 
the  system.  The  mere  reappearance  of  the  eruption  after  a  brief  fading 
is  not  to  be  classified  here;  nor  is  the  simple  return  of  temperature  an 
indication  of  relapse,  since  this  often  occurs,  sometimes  without  the  dis- 
covery of  the  cause  being  possible.  There  must  be  a  combination  of 
symptoms  sufficient  to  justify  the  diagnosis  of  a  true  relapse.  Relapse 
is  seen  oftenest  in  the  middle  or  at  the  end  of  the  4th  week  and  may  be 
either  milder  or  more  severe  than  the  primary  attack.    Lettry^  in  analyz- 

1  Brit.  Journ.  of  Dermatol.,  1910,  XXII,  309. 

2  Jahrb.  f.  Ivindcrh.,  1912,  LXXV,  350. 

3  Boston  City  Hosp.  Reports,  1889. 
♦  Lancet,  1903,  I,  43(5. 

6  TliSse  do  Paris,  1906-7. 


SCARLET  FEVER.     SCARLATINA  329 

ing  46  collected  instances  found  relapse  oftenest  between  the  15th  and 
35th  days. 

Recurrence. — Recurrence  of  the  disease  in  the  form  of  a  distinct 
second  attack  after  a  considerable  interval  is  of  great  rarity.  One  attack 
usually  protects  from  subsequent  ones.  One  hears  of  instances  fre- 
quently, especially  from  the  laity,  but  most  of  these  are  certainly  mis- 
takes in  diagnosis.  Thomas^  reports  a  number  of  undoubted  cases 
collected  from  medical  literature,  but  has  himself  observed  it  but  once 
in  hundreds  of  cases,  and  Henoch^  saw  it  but  once.  J.  McCrae^  reported 
9  instances  said  to  be  second  attacks  in  850  cases  (1  per  cent.),  and 
Weissenberg'*  7  cases.  I  have  treated  one  child  with  2  distinct  and 
undoubted  attacks  separated  by  an  interval  of  a  year. 

In  speaking  of  recurrence  no  reference  is  intended  here  to  that  which 
might  with  some  propriety  be  called  this;  viz.  the  development  of  a  scar- 
latinal angina  in  exposed  adults  who  had  previously  had  the  disease. 

Prognosis. — The  continuously  mild  cases  nearly  invariably  recover; 
yet  cases  beginning  in  this  way  may  later  become  severe,  or  a  dangerous 
complication  or  sequel  may  arise.  The  prognosis  in  every  instance  must, 
therefore,  be  always  most  guarded  throughout.  Only  after  all  danger 
of  sequels  is  over  can  one  feel  at  ease.  The  mortality  appears  to  vary 
greatly  with  the  epidemic  and  is  different  in  different  countries.  Thus 
in  11,216  cases  reported  in  Philadelphia  during  5  years  the  mortality  was 
5.4  per  cent.  (Graham) ;"  and  in  1072  cases  reported  in  1915,  2.4  per  cent. 
(Ostheimer).^  Of  21,834  cases  occurring  in  Hamburg  during  10  years 
6.8  per  cent,  died  (Reincke).'^  Of  15,137  cases  occurring  in  Stockholm 
during  21  years  16.3  per  cent,  died  (Carlson)^  the  lowest  yearly  mortality 
being  2.8  per  cent,  and  the  highest  28.8  per  cent.  Of  1598  cases  in  the 
Manchester  Children's  Hospital  during  10  years  11.8  per  cent,  died 
(Ashby  and  Wright).^  In  1000  cases  in  the  Boston  City  Hospital  the 
mortality  was  9.8  per  cent.  (McCollum).^"  Of  84,380  cases  in  Norway 
collected  by  Johannessen^^  14.17  per  cent,  died,  while  of  167,840  cases  in 
the  Metropolitan  Asylums  Board's  Hospitals  during  13  years  but  4.3 
per  cent,  died  (Caiger).*- 

These  figures  show  the  great  variation  in  statistics,  but  on  the  whole 
there  appears  to  have  been  a  decidedly  decreasing  mortality,  scarlet  fever 
being  by  no  means  as  serious  an  affection  as  it  was  fifty  or  more  years  ago. 
Roughly  speaking  the  general  mortality  may  be  said  to  vary  from  10 
per  cent,  to  15  per  cent.,  although  it  is  much  less  in  uncomplicated 
cases.  It  is  the  general  experience  that  in  private  practice  among  the 
better  classes  the  death-rate  is  decidedly  less  than  this.  As  compared 
with  the  mortality  from  other  causes  that  from  scarlatina  varies  from 
about  2  per  cent,  to  6  per  cent,  or  more  of  the  total  deaths. 

Certain  conditions,  however,  influence  the  mortality  very  unfavor- 

>  Ziemssen's  Handb.,  1874,  B.  II  Tli  II,  17G. 

*  Kinderkrankheitcn,  1895,  675. 

3  Caimdiiui  Mod.  Assoc.  Journ.,  1911,  1,  293. 

*  Arch.  f.  Kindorh.,  1909,  LII,  17. 

»  Jour.  Anicr.  Med.  Assoc,  1917,  LXVII,  1272. 
«  Amer.  Journ.  Pub.  Health,  1910,  VI,  1104. 

'  Bericht  d.  Medicinalraths,  etc.,  1894,  58.  Ref.  v.  Jiirgensen,  Nothiiagers  Ency- 
clopedia of  Tract.  Med.,  Scarhitina,  G03. 

*  Ref.  V.  Jurnensen,  loc.  cit.,  G03. 
»  Dis.  of  Child.,  1893,  240. 

i*  Report  lioston  City  Hospital,  1899. 

"  Die  epidcMi.  V'crbrtutuuK  d.  iS«'harlachfieber  in  Norwegen,  1884. 

'2  Allbutt  and  Rolleston,  8yst.  of  Med.,  190G,  II,  1,  429. 


330  THE  DISEASES  OF  CHILDREN 

ably.  Age  is  a  prominent  factor  here,  the  disease  being  much  more  fatal 
in  children  under  5  years.  Seitz^  found  the  mortality  40.6  per  cent,  in 
the  1st  3'ear  of  life.  In  general  the  younger  the  patient  the  greater  is 
the  danger  of  death.  The  development  of  severe  nephritis  during  the 
attack  greatly  increases  the  death-rate.  Post-scarlatinal  nephritis  does 
so  to  some  extent,  although  to  a  much  less  degree.  Symptoms  of  sepsis, 
especially  those  dependent  on  severe  involvement  of  the  throat,  are  un- 
favorable. In  proportion  also  to  the  intensity  of  the  action  of  the  scar- 
latina toxin  the  danger  grows.  Hence  malignant  cases  are  nearly 
invariably  fatal.  A  very  rapid  pulse,  an  unusually  high  temperature, 
evidence  of  decided  involvement  of  the  nervous  system  or  of  the  throat, 
and  an  irregularly  or  poorly  developed  eruption  if  accompanied  by  severe 
symptoms  all  point  to  the  existence  of  a  grave  case. 

Diagnosis. — This  is  not  difficult  in  typical  cases,  and  rests  chiefly 
on  the  sudden  onset  with  vomiting,  high  fever  and  sore  throat,  followed 
by  the  rapid  development  and  characteristic  spread  of  the  punctate 
eruption,  and  later  the  peculiar  desquamation.  In  very  mild  cases, 
however,  as  well  as  in  the  rapidly  malignant  ones,  the  diagnosis  is  often 
extremely  difficult  or  even  impossible.  In  the  latter  the  rash  may  be 
entirely  uncharacteristic  or  even  absent.  In  the  former  it  may  be  limited 
to  a  small  area,  poorly  developed  or  transitory  and  entirely  overlooked, 
the  tongue  and  throat  may  not  present  typical  changes,  and  desquama- 
tion may  not  be  discovered.  Other  cases  may  present  only  the  affec- 
tion of  the  throat  without  the  cutaneous  eruption.  In  some  instances 
no  desquamation  can  be  found  at  any  time,  especially  if  inunction  has  been 
employed.  In  Negroes  the  diagnosis  is  often  very  difficult,  owing  to  the 
concealment  of  the  eruption  by  the  dark  hue  of  the  skin.  In  some  such 
instances  only  the  occurrence  of  nephritis,  otitis,  or  other  sequel, 
or  of  the  characteristic  desquamation,  makes  the  diagnosis  clear.  It  is 
the  clinical  picture  as  a  whole  rather  than  any  one  symptom  upon  which 
the  diagnosis  must  be  based. 

As  an  aid  to  the  recognition  of  the  scarlatinal  eruption  Pastia^  de- 
scribed a  uniform  linear  redness  in  the  transverse  fold  of  the  skin  at  the 
elbow,  more  intense  than  the  scarlatinal  eruption.  It  is  present  at  the 
very  beginning  of  the  eruptive,  stage  and  lasts  after  the  rash  has  faded. 
It  appears  to  be  produced  by  capillary  hemorrhages.  Its  presence  in 
scarlet  fever  and  its  absence  in  measles  is  confirmed  by  Bizzarri^  and  by 
Lippmann.'*  The  Rumpel-Leede  sign^  is  another  supposed  evidence  of 
the  existence  of  scarlet  fever.  It  consists  in  the  development  of  punc- 
tate hemorrhages  into  the  skin  of  the  elbow-fold  after  compression  of 
the  upper  arm  has  continued  from  5  to  20  minutes.  It  is  claimed  to  be 
especially  applicable  early  in  the  disease.  Experiments  by  MichaeP 
showed  that  a  positive  sign  could  be  elicited  in  normal  children  and  was, 
therefore,  no  proof  of  the  existence  of  scarlet  fever.  Leede  believed  that 
a  negative  result  excludes  scarlet  fever. 

Certain  diseases  are  especially  to  be  distinguished  from  scarlet  fever. 
Rubella  presents  at  times  the  closest  possible  resemblance,  and  even  care- 
ful and  repeated  observation  may  not  solve  the  question  in  isolated  cases, 

1  Miinch.  med.  Wochenschr.,  1898,  XLV,  76. 

2  Arch,  de  in6d.  des  enf.,  1911,  XIV,  130. 

3  La  Pediatria,  1912,  XX,  898. 
*  Pediatrics,  1912,  XXIV,  3.58. 

5  Rumpel,    Munch,    med.   Wochenschr.,   1909,  LVI,    1404;  Leede,    Munch,  med. 
Wochenschr.,  1911,  LVIII,  293;  1673. 

6  Arch,  of  Ped.,  1912,  XXIX,  298. 


SCARLET  FEVER.     SCARLATINA  331 

or  even  in  localized  epidemics.  The  absence  of  general  symptoms  and 
of  scarlatinal  changes  in  the  mouth  and  throat  aid  in  its  recognition.  So, 
too,  there  may  nearly  always  be  found  somewhere  on  the  body  the  charac- 
teristic macular  eruption  of  rubella,  even  when  the  greater  part  of  the 
surface  is  covered  by  a  scarlatiniform  rash.  (See  Rubella.)  Yet  I  do 
not  know  of  other  two  affections  where  differential  diagnosis  can  be  at 
times  the  source  of  more  perplexity.  Measles  seldom  causes  any  con- 
fusion. When  it  presents  a  poorly  developed  eruption  it  may,  how^ever, 
be  distinguished  from  some  cases  of  scarlet  fever  only  with  the  greatest 
difficulty.  The  longer  incubation  and  invasion,  and  the  catarrhal  symp- 
toms of  the  latter;  the  buccal  eruption  and  the  slower  development  of 
the  rash  are  suggestive. 

Diphtheria,  if  attended  by  an  erythema  in  the  early  stages,  may  not  be 
at  first  distinguishable  from  scarlet  fever  with  severe  anginose  symptoms. 
The  difficulty  arises,  too,  in  the  cases  of  scarlet  fever  in  which  no  rash 
was  discoverable.  The  close  study  of  the  sequence  of  symptoms  will 
often  be  of  service.  The  rash  in  diphtheria  is  not  very  frequent,  and 
is  generally  confined  to  the  trunk.  The  discovery  of  the  Klebs- 
Loeffler  bacilli  would  settle  the  question,  were  it  not  that  the  two  diseases 
may  be  combined.  Consequently  a  positive  diagnosis  is  sometimes 
impossible. 

Scarlatiniform  Erythema  is  one  of  the  most  puzzling  conditions  so  far 
as  diagnosis  is  concerned.  This  erythema  may  be  due  to  sepsis,  other 
infectious  diseases,  various  medicaments,  or  to  acute  desquamative 
dermatitis.  It  is  not  infrequent  in  infants  with  slight  disturbance  of 
digestion.  Sepsis  is  the  cause  in  diphtheria,  and  also  probably  in  the 
majority  of  the  cases  called  "surgical  scarlet  fever."  The  rash  resembles 
that  of  scarlet  fever  in  appearance,  and  may  be  followed  by  desquama- 
tion. The  history  of  the  case,  the  failure  of  development  of  the  eruption  in 
the  usual  sequence  and  extent,  and  the  absence  of  the  other  symptoms  of 
scarlatina  aid  in  the  diagnosis.  Typhoid  fever,  grippe  and  varicella 
occasionally  exhilnt  an  erythema  early  in  the  attack  and  this  may  make 
the  diagnosis  at  first  obscure.  The  absence  of  the  scarlatinal  sj'-mptoms, 
the  transitory  character  of  the  rash,  and  the  appearance  later  of  the 
other  manifestations  characteristic  of  these  different  diseases  remove 
the  difficulty  in  diagnosis.  The  prodromal  erythema  of  variola  is  dis- 
tinguished by  its  peculiar  localization.  Various  erythemata  caused  by 
drugs  are  at  times  perplexing.  Among  these  are  especially  those  due  tr 
quinine,  chloral,  salicylic  acid  compounds,  belladonna,  antipyrine,  and 
animal  sera,  especially  the  diphtheria  antitoxin.  Local  irritants  such 
as  mustard-plasters  have  often  been  the  source  of  confusion.  The  occur- 
rence of  the  atropine  eruption  has  especially  been  a  cause  of  alarm  to 
parents.  In  none  of  these  are  the  other  symptoms  of  scarlet  fever  pres- 
ent, except  that  occasionally  the  eruption  may  be  accompanied  by  fever 
and  vomiting.  (Quinine  will  sometimes  produce  a  scarlatiniform  erup- 
tion followed  by  very  characteristic  scarlatiniform  desquamation.  Acute 
des(juamative  dermatitis  (rcu'urrent  exfoliating  dermatitis)  is  a  peculiar 
affection  which  may  resemble  scarlet  fever  very  closely.  Probably 
cases  supposed  to  be  second  and  third  attacks  of  scarlet  fever  are  really 
instances  of  the  disease.  It  is  attended  by  fever,  a  widespread  erythe- 
matous eruption,  and  often  by  desquanuition  which  may  even  occur  in 
the  form  of  casts  of  the  skin  of  the  hands  and  feet,  as  in  some  cases  of 
scarlet  fever.  In  these  respects  it  cannot  be  distinguished  from  scarlet 
fever.     Pharyngeal  symptoms  are,  however,  absent. 


332  THE  DISEASES  OF  CHILDREN 

Treatment.  (A)  .Prophylaxis.  Quarantine. — Every  case  of  sus- 
pected scarlet  fever  should  be  isolated  at  once,  and  kept  so  until  all  danger 
of  the  infection  of  others  is  over.  The  attempt  to  limit  the  spread  of  the 
disease  offers  much  greater  chance  of  success  than  in  the  case  of  some  of  the 
other  infectious  fevers.  How  long  the  quarantine  should  last  is  uncertain. 
At  least  6  weeks  should  be  the  rule,  and  longer  than  this  if  desquamation 
or  purulent  discharge  from  the  ears  or  nose  is  present.  This  is  in  view  of 
the  infectiousness  which  possibly  inheres  in  the  contaminated  scales  and 
certainly  in  the  discharges.  The  studies  of  a  number  of  observers, 
however  (Millard;^  Lauder), ^  indicate  that  this  time  is  unnecessarily  long; 
and  that  4  or  5  weeks  insures  as  great  safety  as  6,  provided  there  is  no 
abnormal  discharge  from  the  nose  or  ears.  Priestly^  sent  home  from  the 
hospitals  120  individuals  still  desquamating;  with  no  development  of  the 
disease  following  in  other  members  of  the  families.  These  cases,  however, 
had  been  anointed  systematically  with  a  disinfectant.  The  general 
methods  for  preventing  the  spread  of  the  disease,  the  selection  of  the 
room  and  care  of  the  patient,  and  the  management  of  other  children  in 
the  family,  are  described  under  General  Management  of  Infectious 
Diseases  (p.  306),  and  must  be  strictly  followed.  Preventive  inoculation' 
was  attempted  years  ago  by  various  physicians  without  satisfactory 
results.  In  recent  years  similar  efforts  have  been  made  and  good  results 
reported.  Gabritschewsky*  employed  a  form  of  preventive  vaccination 
in  about  50,000  children  and  claimed  success.  This  has  been  confirmed 
by  some  observers,  but  found  without  value  by  others  (Kolmer).^ 

(B)  Treatment  of  the  Attack. — There  is  no  method  known  which  cur- 
tails the  attack  in  any  way.  The  treatment  is  purely  symptomatic. 
The  patient  should  be  kept  absolutely  in  bed  until  desquamation  is  over. 
The  confinement  to  bed  should  continue  for  at  least  3  weeks  even  in  the 
mild  cases.  The  diet  should  if  possible  be  liquid  until  the  temperature 
is  normal,  milk  being  by  far  the  best  food.  Where,  as  is  often  the  case  with 
small  children,  the  appetite  is  lost  and  milk  is  refused,  some  of  the  cereal 
foods  may  be  tried  early,  and  the  diet  varied  considerably.  After  fever  has 
ceased  a  diet  of  cereals  and  milk  is  always  in  order,  reserving  meat  and 
eggs  until  the  end  of  at  least  the  3d  week  of  the  disease.  This  plan  of 
treatment  throws  less  work  upon  the  kidneys.  The  injuriousness  of 
meat  in  this  disease  has  been,  however,  disputed.  Gerstley*^  in  a  trial 
upon  306  cases,  half  of  them  given  the  ordinary  full  diet,  could  see  no 
difference  in  the  incidence  of  nephritis.  These  results  confirm  the  ob- 
servations of  Popischill  and  Weiss,''  but  are  opposed  to  the  opinion  and 
practice  of  the  majority  of  pediatrists.  Water  to  drink  should  be  admin- 
istered freely.  Daily  warm  ablution  should  be  given  to  every  child  for 
the  sake  of  cleanliness  and  comfort,  with  proper  precautions  against 
exposure,  washing  being  done  under  the  bed-clothes,  or  with  the  uncov- 
ering of  but  one  portion  of  the  body  at  a  time. 

The  room  should  not  be  hot,  and  fresh  air  is  an  essential,  but  draughts 
must  be  carefully  avoided  during  the  apyretic  period  of  convalescence. 
Much  has  been  written  of  the  innocuousness  of  exposure  to  draughts  of 
air  in  this  disease.     While  it  is  undoubtedly  true  that  infection  is  the 

1  Lancet,  1902,  Apr.  5 

2  Lancet,  1904,  I,  712. 

3  Transac.  Epid.  Soc,  1894-5,  XIV,  71. 

'  Ref.  Wladimiroff,  Arch.  f.  Kinderh.,  1909,  LII,  28. 
6  Arch.  Int.  Med.  1912,  IX,  220. 
«  Monatsschr.  f.  Kandcrh.,  Orig.,  1913,  XII,  121. 
^  Ueber  Scharlach,  1911.     Ref.  Gerstley,  loc.  cit. 


SCARLET  FEVER.     SCARLATINA  333 

active  cause  in  the  production  of  nephritis  and  other  complications, 
there  seems  no  good  reason  why  surface-chilling  may  not  act  as  a  predis- 
posing cause,  and  why  no  precaution  should  be  taken  against  it.  The 
bed-covering  should  be  light,  the  sensations  of  the  patient,  when  these 
can  be  ascertained,  being  the  best  guide.  The  skin  should  be  kept  oiled 
with  petrolatum  or  a  weak  carbolized  oil  (2  per  cent.)  or,  in  the  case  of 
young  children,  with  a  1  per  cent,  thymol  ointment.  This  allaj^s  the 
itching  and  prevents  also  the  dissemination  of  the  scales,  at  the  same 
time  disinfecting  them,  if  thej^  have  become  soiled  by  mucus  or  purulent 
secretion,  and  favors  a  more  rapid  desquamation.  The  mouth,  throat, 
and  nose  should  be  examined  daily  in  order  that  appropriate  treatment 
may  be  commenced  at  once  if  indicated.  (See  p.  335.)  The  employment 
of  mild  antiseptic  gargles  and  sprays  aids  in  preventing  the  development 
of  any  serious  trouble  here.  The  urine  also  should  be  examined 
frequently. 

Little  internal  medication  is  needed.  Stimulation  is  not  required  in 
ordinary  cases.  A  mild  diuretic,  such  as  citrate  of  potash,  is  of  advantage 
in  maintaining  diuresis  without  irritation  of  the  kidneys.  Various  drugs 
have  at  different  times  been  recommended  as  specifics.  None  of  these 
have  proven  of  any  certain  value. 

Much  has  been  written  regarding  the  serum-treatment  of  scarlet  fever, 
but  without  any  generally  accepted  conclusions.  Marmorek's^  anti- 
streptococcic serum  has  been  tried  in  scarlet  fever  on  the  ground  that  a 
streptococcus  was  the  cause  of  the  disease.  In  Baginski's^  experience 
this  proved  of  doubtful  service.  Later  a  serum  was  advocated  by 
Aronson,^  obtained  by  inoculation  of  horses  with  streptococci  from 
scarlet  fever  patients  after  repeated  passage  of  the  cultures  through 
animals  by  inoculation.  The  value  of  this  serum  has  not  yet  been 
satisfactorily  demonstrated.  Moser^  produced  a  polyvalent  serum  in  a 
somewhat  similar  manner  using,  however,  cultures  from  the  blood  of 
scarlatinal  patients,  and  inoculating  horses  without  previous  strengthen- 
ing of  the  toxins  by  animal  transmission.  He  claimed  excellent  results 
with  this,  and  these  have  been  supported  by  many  investigators,  as 
Escherich^  and  many  others,  while  Heubner,^  Ganghofner^  and  others 
obtained  no  favorable  results.  (For  a  careful  review  see  article  by 
Fedinski.)^  If  scarlet  fever  is  dependent  upon  a  streptococcus,  which 
has  not  as  yet  been  proven,  it  is  evident  that  good  results  from  any  anti- 
streptococcic serum  can  be  hoped  for  only  in  cases  where  the  danger 
is  from  the  septic  manifestations.  Under  such  circumstances  the  treat- 
ment may  well  be  tried.  The  serum,  if  given  in  large  doses,  100  to  200 
c.c.  (3.4  to  6.8  fl.oz.)  at  a  time,  and  in  the  first  3  or  4  days,  offers  the 
greatest  likelihood  of  doing  good.  Lej^den'-*  viewed  favorably  the  employ- 
ment of  blood-serum  of  patients  convalescing  from  the  disease,  and 
Landsteiner  and  Levaditi,^"  and  Zingher^'  report  surprising  results  some- 

1  Ann.  de  I'inst.  Pasteur,  189(5,  X,  47. 

2  Berl.  klin.  Wochcnschr.,  189(),  MQ. 

3  Verhnndl.  Berl.  mod.  Ges.,  1902,  XXXIII,  253. 
*  .lalirb.  f.  Kindorh.,  1903,  LVII,  1. 

s  Wion.  klin.  Wochcnsolir.,  1903,  XVI,  6G3. 
0  Hcrl.  klin.  Woclien.schr.,  1904.  XIJ,  373. 
'  Douf.  mod.  Wochcn-sclir.,  1905,  Apr.  .5,  529. 
»  .luliihuch  f.  Kinderh.,  1910,  LXXl,  S9. 
»  Miincli.  nied.  Wochonsclir.,  1902,  l.")9. 
'»  .\nii.  (If  riiisf.  Pasteur,  1911,  XXV,  7.54. 
'^  Journ.  Anier.  Med.  -Vssoc.,  1915,  LXV,  875. 


334  THE  DISEASES  OF  CHILDREN 

times  seen  in  severely  ill  patients.     Not  less  than  50  c.c.  (1.7  fl.oz.) 
should  be  given  intravenously  or  into  the  muscles. 

The  treatment  of  some  of  the  more  important  symptoms  and  com- 
plications may  be  considered  separately: 

Fever. — A  temperature  of  104°F.  (40°C.)  lasting  for  a  short  time  is 
generally  a  matter  of  no' special  consequence.  When,  however,  high  fever 
is  prolonged  and  is  accompanied  by  nervous  symptoms,  treatment  is  re- 
quired. Hydrotherapeutic  measures  are  generallj^  much  to  be  preferred 
to  internal  medication.  Sponging  with  luke-warm  water  or  with  alcohol 
and  water  ma}^  be  emploved.  If  this  is  not  sufficient,  sponging  with 
water  at  a  temperature  of  70°  to  80°F.  (21.1°  to  26.7°C.)  may  be  tried, 
or  in  urgent  cases  cooler  than  this.  Great  discretion  must  be  exercised, 
hoAvever,  in  young  children  and  especially  in  infants,  since  these  often  do 
not  bear  cold  water  well  in  any  febrile  disorder.  Every  case  must  be 
treated  as  an  individual  and  all  depression  of  pulse-strength  assiduously 
avoided.  Very  often  submersion  in  a  tepid  bath  of  85°  to  90°F.  (29.4° 
to  32.2°C.)  or  even  in  a  warm  bath  of  90°  to  100°F.  (32.2°  to  37.8°C.) 
will  effect  decided  reduction  of  temperature.  In  very  urgent  cases  the 
graduated  bath  maj^  be  employed,  the  temperature  of  the  water  after 
the  child  is  in  the  tub  being  gradually  reduced  to  even  70°F.  (21.1°C.);' 
rarely  lower  than  this.  The  warm  or  cold  pack  frequently  repeated  is 
often  very  useful  and  better  tolerated  than  the  bath.  Hydrotherapy 
must  always  be  used  with  especial  caution,  if  at  all,  where  decided 
cardiac  weakness  exists.  When,  too,  good  reaction  does  not  take  place, 
or  when  a  young  child  fights  violently  against  the  treatment,  it  may  some- 
times do  more  harm  than  good. 

The  employment  of  antipyretic  drugs  of  the  coal-tar  series  for  the 
reduction  of  temperature  is  only  exceptionally  indicated.  There  are 
times,  however,  when  they  are  very  serviceable,  when  for  any  reason 
hydrotherapy  cannot  be  employed.  They  should  be  given  in  small 
doses  frequently  repeated. 

Nervous  symptoms  attending  high  temperature  are  often  much  bene- 
fited by  hydrotherapy.  Indeed,  it  is  the  combating  of  these,  rather  than 
the  simple  reduction  of  temperature,  which  is  the  chief  aim  of  hydro- 
therapeutic  measures.  An  ice  cap  to  the  head  is  frequently  of  advantage 
under  these  circumstances.  The  coal-tar  derivatives  employed  to 
combat  nervous  symptoms  have  a  value  much  greater  than  that  of  the 
mere  reduction  of  fever  which  they  effect.  Their  administration  is  often 
followed  by  the  relief  of  delirium,  stupor,  jactitation  or  a  convulsive 
condition,  which  is  greater  than  can  be  attributed  to  the  fall  of  tem- 
perature. M}^  own  preference  is  for  phenacetin  or  antipyrine.  It  is 
important  to  give  repeated  small  doses  rather  than  a  single  larger  one, 
since  a  decided  fall  of  temperature  may  be  attended  by  prostration.  In 
the  majority  of  instances  hydrotherapy  is  to  be  preferred.  For  the 
convulsions  developing  during  scarlatinal  nephritis  both  Allaria^  and 
Sheffield^  have  seen  benefit  from  the  employment  of  lumbar  puncture. 

Cardiac  weakness,  as  shown  by  the  rapid  and  feeble  or  irregular 
pulse,  weak  heart-sounds,  or  persistent  coldness  and  cyanosis  of  the 
extremities,  demands  the  prompt  and  energetic  use  of  stimulants.  Even 
before  these  symptoms  have  actually  made  their  appearance,  but  where, 
as  in  septic  cases  or  those  with  prolonged  high  temperature,  it  is  feared 
that  weakness  of  the  heart  may  develop,  stimulants  may  well  be  employed. 

1  Gaz.  dcgli.  osp.  ed  del.  clin.,  1911,  XXXII,  1291. 

2  Pediatrics,  1912,  XXIV,  99. 


SCARLET  FEVER.     SCARLATINA  335 

Digitalis,  stiychnine  and  alcohol  by  the  mouth,  or  camphor  and  caffeine 
given  hypodermically,  may  be  selected  according  to  the  demands  of  the 
case. 

Inflammation  of  the  throat  and  nose  when  mild  requires  no  special 
medication.  When  more  severe,  as  in  anginose  cases,  it  often  demands 
active  treatment,  the  nature  and  frequency  of  which  varies  with  the  case. 
The  nose  may  be  sprayed  or  syringed  gently  with  normal  salt  solution  or 
with  mild  antiseptic  solutions  (boric  acid,  liquor  antisepticus  alkalinus, 
etc.)  repeated  several  times  a  day.  Antiseptic  gargles  should  be  em- 
ployed, or,  in  case  the  child  cannot  or  will  not  use  these,  swabbing  of  the 
throat  with  cleansing  and  antiseptic  solutions  as  for  pharyngitis  and 
tonsillitis  of  other  nature.  Diluted  peroxide  of  hydrogen  is  often  to  be 
recommended,  or  solutions  of  potassium  permanganate  or  of  corrosive 
sublimate.  When  a  pseudodiphtheritic  membrane  has  formed  appli- 
cation of  diluted  peroxide  of  hydrogen  (1:2  of  water)  may  be  used, 
followed  by  diluted  tincture  of  the  chloride  of  iron  (1:4)  or  of  bichloride 
of  mercury  (1:5000),  or  nitrate  of  silver  (gr.  5  or  10:  oz.  1)  (0.324  or 
0.648:30).  When  local  treatment  is  attended  by  great  resistance  on  the 
part  of  the  child,  as  is  often  the  case,  the  advisability  of  continuing  it  is 
questionable.     Its  importance  must  be  determined  for  each  individual. 

Otitis  can  probably  be  prevented  to  some  extent  by  persistent  dis- 
infection of  the  throat  and  nose.  The  constant  wearing  of  a  flannel  cap 
over  the  ears,  and  the  use  of  a  hot  water  bag  or  of  hot  water  douching 
of  the  canal,  is  of  benefit  as  a  preventive  or  if  the  disease  has  developed. 
In  the  latter  event  paracentesis  may  become  necessary.  If  perforation 
of  the  drum-head  has  taken  place  the  usual  treatment  of  suppurating 
otitis  media  is  necessar3^ 

Adenitis  may  often  be  aborted  by  the  application  of  an  ice-bag,  tinc- 
ture of  iodine,  flexible  collodion,  or  a  15  per  cent,  ointment  of  ichthj'ol. 
The  ice-bag  should  be  of  thin  rubber  and  kept  constantly  in  position,  with 
a  thin  layer  of  cloth  between  it  and  the  skin.  If  it  is  evident  that  suppura- 
tion will  take  place  hot  compresses  or  poultices  may  be  employed  to 
hasten  the  process  and  to  relieve  the  pain.  Early  evacuation  of  the  pus 
is  indicated. 

Nephritis  requires  prompt  treatment.  Whether  anything  can  be 
done  to  prevent  its  development  is  a  much  disputed  question.  The 
avoidance  of  surface-chilling  and  the  employment  of  an  unirritating 
diet  have  already  been  mentioned.  A  salt-free  diet  has  been  urged 
by  Pater,  1  Delearde^  and  others,  but  Nobecourt  and  Merklen''  found 
albuminuria  less  frequent  when  milk  alone  was  employed.  Widowitz,^ 
Buttersack*  and  others  have  strongly  recommended  the  administration 
of  hexamethylenamine  as  a  preventive  measure,  and  Royer'"'  confirmed 
previously  published  reports  upon  the  value  of  chloral  given  for  the  same 
purpose. 

When  nephritis  has  developed,  if  of  but  slight  severity,  the  frequently 
repeated  application  of  hot  poultices  over  the  renal  region,  the  use  of 
warm  baths,  and  the  administration  of  mild  diuretics,  such  as  acetate  of 
potash,  citrate  of  potash  and  sometimes  of  digitalis,  are  sufl^cient.     Stimu- 

1  Bull.  et.  mem.  soc.  m6d'.  des  hAp.,  190(),  XXII I,  Oil 

^  L'Ei'ho  iii6d.  du  nord.,  1907.  XI,  'ifi. 

••'  Arch,  do  iii^d.  dps  ciif.,  HHIS,  XI.  SI. 

*  Wicii.  klin.  Wnchciisclir.,'Ht():],  XVI,  1113. 

'  Dciit.  Arch.  klin.  Mod.,  1!){)4,  LXXX,  35G. 

«  retina.  Mod.  .Journ.,  1<»()7,  X,  2Sl). 


336  THE  DISEASES  OF  CHILDREN 

lating  diuretics  must  never  be  employed.  When  the  nephritis  is  more 
severe,  with  anuria  or  great  diminution  of  the  amount  of  urine,  convul- 
sions, vomiting,  and  the  symptoms  of  uremia,  the  treatment  must  be 
energetic.  This  is  discussed  more  fully  in  the  chapter  upon  Acute 
Nephritis,  Vol.  II,  p.  181. 

Arthritis  may  well  be  treated  with  salicylic  acid  combinations  on 
the  ground  that  it  may  be  rheumatic  in  nature.  If  it  is  but  slight,  local 
protection  of  the  joints  may  be  all  that  is  required.  Purulent  inflam- 
mation of  the  joints  is  to  be  subjected  to  surgical  measures. 

The  treatment  of  other  complications  and  sequels  does  not  require 
special  consideration  here.  During  convalescence,  especially  from  a 
severe  attack,  tonic  measures  are  indicated,  including  the  administration 
of  iron  to  combat  the  anemia  which  often  results. 


CHAPTER  III 

MEASLES 
(Rubeola.     Morbilli) 


Measles  was  undoubtedly  known  to  the  ancients,  but  was  confounded 
by  them  with  several  other  diseases.  It  was  differentiated  clearly 
from  small-pox  by  Rhazes^  about  900  A.  D.  and  from  scarlet  fever  by 
Sydenham^  in  the  middle  of  the  17th  Century. 

Etiology.  Predisposing  Causes. — Race,  sex,  climate  and  locality, 
social  position,  and  sanitation  appear  to  exert  no  influence  on  the 
occurrence  of  the  disease.  The  presence  of  other  acute  disorders 
occasionally  delays  the  appearance  of  the  symptoms  of  measles,  but 
does  not  prevent  it.  Age  is  a  very  important  factor.  The  susceptibility 
in  the  latter  half  of  the  1st  year  is  disputed,  but  it  is  agreed  that 
infants  in  the  first  6  months  are  much  less  often  attacked  than  later. 
Yet  even  instances  of  congenital  measles  are  recorded,  Ballentyne^ 
having  collected  21  such  from  medical  literature.  Additional  cases  of  the 
presence  of  measles  at  or  developing  a  few  days  after  birth  have  been 
reported  by  Mason,^  Steinschneider'^  and  Rocaz.'' 

Whether  the  infrequency  in  nurslings  is  due  to  lesser  susceptibility,  or 
to  lesser  frequency  of  exposure  is  not  certainly  determined.  Lichtenstein^ 
observed  40  nurslings  attacked  out  of  47  exposed  to  infection,  this 
appearing  to  be  contrary  to  the  usual  experience.  After  the  1st  year 
the  influence  of  age  ceases.  That  few  exposed  adults  suffer  from  the 
disease  clearly  depends  on  the  fact  that  so  many  have  already  had  it. 
In  the  epidemic  of  1846  in  the  Faroe  Islands,  described  by  Panum,* 
where  no  one  was  thus  protected,  adults  of  every  age  proved  as  susceptible 
as  children,  and  no  instance  was  met  with  where  an  unprotected  adult 
exposed  did  not  take  the  disease. 

1  De  variolis  et  morbillis,  1756. 
-  Processus  integri. 
3  Arch,  of  Pediat.,  189.3,  X,  301. 
*  Boston  Med.  and  Surg.  Journ.,    1908,  CLIX,  437. 
5  Deutsch.  med.   Wochenschr.,   1914,  XL,  441. 
«  Gaz.  hebdom.  des  sci.  ni6d.  de  Bordeaux,    1908,  XXVII,  260. 
'  Hvgeia,  1914,  LXXVI,  1022.     Ref .  Monatsschr.  f.  Kinderh.     Ref .,  1915,  XIV,  455. 
8  Verhandl  d.  physik.-med.  Gesellsch.  in  Wurzburg,  1851,  II,  292,  293 ;  Virchow's 
Archiv  1847,  1,  492. 


I 

i 


MEASLES  337 

The  individual  susceptibility  is  very  great,  exceeding  that  of  most  of 
the  other  infectious  diseases.  In  the  Faroe  Islands'  epidemic  over  6000 
of  7782  inhabitants  were  attacked,  1500  escaping  only  through  the 
institution  of  absolute  quarantine  in  certain  villages.  Later,  in  the 
epidemic  of  1875,  as  described  by  Hoff,^  99  per  cent,  of  the  unprotected 
inhabitants  of  Thorshaven  were  affected.  In  my  own  experience  measles 
is  one  of  the  most  readily  contracted  of  the  diseases  of  its  class,  the  suscepti- 
bility to  it  being  so  great  that  spread  of  the  infection  is  little  controllable. 
Yet  a  certain  individual  immunity,  it  is  true,  temporary  or  permanent, 
is  occasionally  met  with.  A  decided  epidemic  influence  exists  also, 
measles  being  much  more  frequent  or  severe  in  certain  years  than  in  others, 
especially  in  localities  where  it  is  always  endemic  to  some  extent.  This 
may  depend  upon  a  greater  virulence  of  the  poison  in  some  years,  and  a 
consequent  greater  tendency  to  spread.  There  is  no  regularity  in  the 
return  of  these  epidemic  outbreaks.  Season  seems  to  possess  a  slight 
influence,  the  disease  being  more  prevalent  in  winter,  and  especially  in 
spring,  than  in  summer.  Of  530  epidemics  studied  by  Hirsch^  339  (64 
per  cent.)  occurred  in  the  colder  part  of  the  year,  and  191  (36  per  cent.) 
in  the  warmer.  In  213  of  the  epidemics  the  height  was  reached  in  76  in 
spring,  59  in  winter,  48  in  autumn  and  30  in  summer.  Yet  the  greater 
prevalence  in  the  cooler  months  may  depend  upon  the  closer  confinement 
and  consequent  more  intimate  association  in  houses  and  especially  in 
schools. 

Exciting  Cause.— This  is  without  doubt  a  germ  of  some  sort.  Canon 
and  Pielicke''  and  Czajkowski^  described  a  short  bacillus  constantly 
present  in  the  blood  and  the  nasal  secretion.  Bacilli  have  also  been 
found  in  the  blood  by  Arsamakov,"  Zlatogoroff,*^  Von  Niessen,^  Giarre 
and  Picchi^  and  others.  Micrococci  have  been  reported  in  the  blood 
and  the  nasal  mucus  by  Lesage^  and  in  the  blood,  throat,  nose,  and  eyes 
by  Tunnicliff.^''  An  ameba-like  body  was  found  in  the  red  corpuscles  by 
Doehle,^^  Behla,^^  and  later  by  Rosenberger.^^ 

In  this  connection  the  various  experiments  upon  the  possibility  of  the 
transmission  of  the  disease  to  other  animals  are  of  interest  and  importance. 
Goldberger  and  Anderson^"*  succeeded  in  producing  the  disease  in  monkeys 
by  inoculating  with  virus  obtained  from  the  secretions  and  the  blood. 
As  this  was  accomplished  after  passing  the  material  through  a  Berkfeld 
filter,  the  etiological  relationship  of  any  of  the  microorganisms  previously 
reported  would  appear  to  be  disproved,  and  the  germ  must  be  ultra- 
microscopic.  The  transmissibility  to  monkeys  has  been  confirmed 
by  Hektocn  and  Eggers^^  and  by  Lucas  and  Prizer.^''     The  true  nature  of 

'  SundhedskoUcKiets  Aarsberetning  1876.     Ref.  von  Jurgensen,  Nothnagel's  Ency- 
clop.  Amer.  Ed.,  Measles,  228. 

2  Handh.  d.  histor.  geog.  Path.  1881,  116. 
'  Bed.  klin.  Wochenschr.,  1892,  Apr.   317. 

*  Centralbl.  f.  Bakt.,  189.5,  XVIIl,  517. 

'  Bolnitch  Gaz.  Botk.  1898,  40.     Ref.  Rev.  de  mM.,   1899,  XIX,    561. 
•Centralbl.  f.  Bakt.  1904,  XXXVII,  249. 
'  Arch.  f.  Derm.  u.  Syph.,  1902,  LX,  429. 

*  Acad.  mcd.  phys.  fiorcnt.,   1900. 

"  Compt.  rend,  de  la  soc.  de  biol.,  1900,  LI,  1203. 
'">  Jourii.  Atticr.  Med.  As.soc.,  1907.  LXVllI,  102S. 
k"  Centralbl.   f.  allg.   Path.  u.   path.   Anat.,   1892,  III,   150. 
'2  Centrall)!.  f.   Bakt.,   1896,  XX,  561. 
"  Amer.   Med.,   1906,  XII,   139. 

"Journ.  Amer.   Med.  A.ssoe.,   1911,  LVII,  47();  971;   1612. 
"*Journ.  Amer.   Med.  As-soc.   1911,  LVll,   1S83. 
'Uoiirn.  Med.  Research,   1912,  XXVI,   181. 

22 


338  THE  DISEASES  OF  CHILDREN 

the  microorganism  is,  therefore,  evidently  not  yet  determined.  It  seems 
certain  that  under  the  influence  of  its  presence,  other  germs,  such  as  the 
streptococcus,  pneumococcus  and  the  bacilUis  of  diphtheria,  are  enabled 
to  produce  complications. 

The  germ  is  very  short-lived  in  measles  as  compared  with  scarlet 
fever  and  small-pox.  Positive  data  are  necessarily  lacking,  but  it  is 
probable  that  it  dies  in  from  10  to  14  days  from  the  onset  of  the  attack. 
Its  habitat  is  certainly  the  secretions  of  the  mucous  membrane  of  the  nose, 
mouth,  and  eyes,  and  the  blood;  and  it  is  probable  that  the  desquamating 
epidermis  has  no  infectious  power  unless  contaminated  by  these.  It 
was  found  without  infectivity  by  Anderson  and  Goldberger.  Inocula- 
tion experiments  upon  human  beings,  claimed  to  have  been  successful, 
were  made  with  the  blood  by  Home'  and  by  Hektoen,^  with  the  blood 
mixed  with  serum  from  the  vesicles  by  Katona/  and  with  the  nasal 
mucus  by  Mayr."*  Some  investigators  have  confirmed  these  results, 
while  others  have  failed,  and  further  studies  on  the  subject  are  needed. 

Method  of  Transmission. — This  may  be  either  mediate  or  direct, 
the  latter  occurring  in  the  vast  majority  of  instances.  The  germ  is 
certainly  very  virulent,  and  but  a  brief  exposure  is  necessary.  The 
disease  can  be  communicated  by  way  of  the  air  through  the  mere  pres- 
ence in  the  sick-room,  but  that  it  can  be  carried  any  distance  by  it 
is  entirely  unlikely.  The  experiments  of  Grancher-^  and  others  indicate 
that  it  cannot.  Many  instances  of  transmission  by  fomites  or  by  a  third 
person  are  on  record,  but  are  certainly  exceptional.  The  careful  analysis 
made  by  Jiirgensen^  throws  doubt  upon  some  of  those  oftenest  quoted. 
Some  more  recent  experiences  in  favor  of  mediate  transmission  have  been 
published  by  Roch,^  Rohmer,^  Lanzarini^  and  others.  The  common 
experience,  however,  agrees  with  that  of  Jtirgensen.  The  usual  absence  of 
mediate  transmission  may  be  explained  in  part  by  the  germ's  short 
duration  of  life.  Rooms  which  have  been  occupied  by  patients  with 
measles  can  be  used  with  safety  by  susceptible  subjects  very  soon  after 
the  attack  is  over. 

Period  of  Infectiousness. — It  is  probable  that  the  danger  exists 
during  the  last  part  of  the  stage  of  incubation,  and  certainly  so  from  the 
onset  of  the  invasion  and  during  at  least  a  portion  of  the  period  of  erup- 
tion. The  great  frequency  with  which  the  disease  is  disseminated  by 
schools  and  the  difficulty  of  controlling  its  spread,  proves  the  infectious- 
ness of  the  early  periods.  The  infectiousness  lessens  rapidly  as  the 
catarrhal  symptoms  disappear.  Certainly  the  disease  is  communicated 
in  but  few  instances  during  the  stage  of  desquamation. 

Pathological  Anatomy.- — -There  are  few  characteristic  post-mortem 
lesions.  According  to  Neumann'**  the  principal  changes  in  the  skin  consist 
of  dilatation  of  the  vessels,  with  a  surrounding  infiltration  of  small  cells, 
situated  in  the  upper  portion  of  the  cutis  and  extending  into  the  Mal- 
pighian  layer,  together  with  an  extensive  infiltration  around  the  hair 

1  Medical  Facts  and  ExDeriments,  1759. 

2  Journ.  Infect.  Dis.,  190.5,  II,  238. 

5  Oesterreich.  med.  Wochenschr.,  1842,  697. 

*  Zeitsch.  d.  k.  k.  Gesellsch.  d.  Aerzte  zu  Wien.,  1852,  VIII,  13. 
5  Traite  dea  mal.  de  I'enf.,  2  Ed.,  I,  322. 
^  Nothnagel's  Encyclop.  Amer.  Edit.,   Measles,  247. 
'  Arch,  de  mod.  des  enf.,   1907,  X,    292. 
sjahrb.  f.  Kinderh.,   1912,  LXXV,  78. 
9  La  Pediat.,   1907,  XV,  366. 
10  Med.  Jahrb.,  1882,   159. 


MEASLES  339 

follicles  and  the  sudoriparous  and  sebaceous  glands.  Similar  changes 
are  seen  in  the  mucous  membrane,  a  catarrhal  inflammation  with  a 
small-celled  infiltration,  occurring  in  the  eyes  and  in  the  respiratory  and 
alimentary  tracts.  The  histology  of  the  buccal  eruption,  as  studied  by 
Hlava^  and  by  Flamini^  consists  in  an  interpapillary  injection  of  the 
capillary  vessels,  an  infiltration  with  round  cells,  thickening  of  the  super- 
ficial layer  of  the  epidermis  and  degenerative  changes  of  the  lower  layer, 
forming  a  minute  pustule. 

The  inflammatory  process  is  followed  by  desquamation  of  the  epi- 
thelium of  both  the  skin  and  the  mucous  membrane.  The  lymphoid 
tissues  throughout  the  body,  including  the  lymphatic  glands  everywhere, 
the  tonsils,  spleen  and  the  lymphatic  follicles  of  the  intestinal  tract,  ex- 
hibit decided  cellular  hyperplasia.  Focal  necrosis  of  the  liver  has  been 
described  (Freeman).^ 

Symptoms. — Ordinary  Type.  Period  of  Incubation. — This  period, 
up  to  the  first  appearance  of  catarrhal  symptoms,  has  been  very  accurately 
determined  by  Panum^  and  numerous  other  observers  to  be  10  or  11  days, 
or  14  days  until  the  rash  appears.  Exceptionally  it  may  be  of  slightly 
longer  or  shorter  duration.  In  the  majority  of  cases  no  symptoms  occur. 
Meunier,^  however,  insists  that  incubation  is  constantly  attended  by  a  very 
decided  loss  of  weight  beginning  on  the  4th  or  5th  day.  The  buccal  erup- 
tion, presently  to  be  described,  is  sometimes  discovered  before  the  catarrhal 
symptoms  of  the  stage  of  invasion  begin.  Rolleston^  maintained  that 
ephemeral  prodromal  eruptions,  such  as  urticaria  or  erythema,  appear 
during  the  last  part  of  the  incubative  period  in  nearly  half  of  the  cases 
studied.  The  characteristic  changes  of  the  blood  (p.  344)  begin  to  show 
themselves  during  the  incubative  period. 

Period  of  Invasion. — Occasionally  a  convulsion  or  decided  chilliness  */ 
ushers  in  the  attack,  or  fever  develops  suddenly;  but  as  a  rule  the  onset 
is  gradual,  the  symptoms  being  indistinguishable  from  those  of  a  severe 
general  cold.  The  child  is  irritable,  tired,  chilly,  and  often  peculiarly 
drowsy.  As  the  disease  progresses  there  are  decided  lachrymation, 
photophobia,  redness  of  the  conjunctiva,  coryza,  sneezing,  thirst,  and 
often  a  dry,  hard,  and  sometimes  distressing  cough.  Occasionally  a 
few  dry  rales  are  audible  in  the  chest.  Epistaxis  is  not  uncommon.  The 
upper  lip  is  excoriated  by  the  nasal  secretion,  the  appetite  diminished, 
and  the  tongue  coated,  with  the  edges  perhaps  somewhat  red  and  the 
papillae  here  a  little  enlarged.  Some  soreness  of  the  throat  is  complained 
of,  and  the  pharynx,  fauces  and  tonsils  are  moderately  congested,  the 
latter  being  slightly  swollen.  Vomiting  occasionally  occurs,  and  diar- 
rhea is  not  infrequent.     Headache  is  common  and  delirium  may  occur. 

By  the  2d  or  3d  day  the  characteristic  eruption  may  be  seen  on 
the  mucous  membrane  (enanthem),  consisting  of  small,  red  macules  dot- 
ted over  the  hard  and  the  soft  palate  and  resembling  those  which  appear 
later  upon  the  skin.  It  is  at  its  height  when  the  cutaneous  rash  develops 
and  may  persist  3  or  4  days  more.  A  condition  of  another  sort,  the  so- 
called  "buccal  eruption"  or  "Koplik's  spots,"  is  found  upon  the  mucous 

^Casopis  16karu  ceskych,  1906,  773.  Rcf.  Zcntralbl.  f.  inn.  M(-(l.,  HH)(i,  XXVII, 
923 

^Riv.  di  clin.  pediat.,  1908,  VI,  401. 

3  Arch,  of  Podiat.,   1900,  XVII,  81. 

4  JjQQ    ci-t 

^  Gaz.  liebdom.,   1898,   10.57. 
•Brit.  Med.  Journ.,  1905,  Feb.  4. 


340 


THE  DISEASES  OF  CHILDREN 


lining  of  the  lips  and  cheeks,  oftenest  close  to  the  junction  of  the  latter 
with  the  upper  jaw.  It  consists  of  minute  bluish-white  points  each 
surrounded  by  a  small  slightly  red  areola.  When  the  spots  are  numerous 
the  areolae  coalesce,  giving  a  redder  tint  to  the  whole  lining  of  the  cheeks 
and  lips,  over  which  are  dotted  the  crowded  spots. 

Although  the  buccal  eruption  was  previously  described  by  Rinecker 
and  by  Reubold,^  Flindt,^  Monti,  ^  Filatow,*  and  others,  its  diagnostic 
importance  did  not  receive  general  attention  until  pointed  out  by  Koplik^ 
(Fig.  63).     It  can  be  seen  to  advantage  only  in  bright  daylight,  pref- 


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Fig.  64.  Fig.  65. 

Fig.  64. — Measles  without  Pre-eruptive  Fall  of  Temperature. 
R.  McN.,  4  years  old.     Mar.  6,  vomited;  Mar.  8,  well-marked  catarrhal  symptoms, 
buccal  eruption,  rash  appearing  on  face  and  body;  Mar.  10,  attack  severe;  Mar.  13,  diph- 
theria discovered. 

Fig.  65. — Measles  with  Pre-eruptive  Intermission  in  Temperature. 
Lena  M.     Jan.  30,  catarrhal  symptoms  began;  Feb.  2,  symptoms  been  very  pronounced, 
fall  of  temperature  to  99°;  Feb.  3,  abundant  eruption,  general  symptoms  improved,  but 
temperature  elevated;  Feb.  8,  desquamation. 


erably  by  carrying  the  child  close  to  the  window.  Occasionally  it  may  be 
found  as  much  as  5  days  before  the  cutaneous  rash  develops  (Cotter)  ^  but 
is  oftener  seen  2  to  3  days  before,  and  quite  frequently  is  not  discoverable 
until  after  this  appears.  The  buccal  eruption  is  almost  pathognomonic 
of  measles,  and  is  present  in  from  80  to  90  per  cent,  of  the  cases.     In  the 

1  Virchow's  Archiv.,   1853,  VII,  76. 

2  Ref.  V.  Jiirgensen,  Nothnagel's  Encyclop.,  Amer.  Ed.,  1896,  286. 
=>  Jahrb.  f.  Kinderh.,  1873,  VI,  20. 

*  Dis.  of  Child.  Amer.  Transl.,  1904,  I,  97;  II,  660. 

5  Arch,  of  Pediat.,  1896,  XIII,  918;  Med.  News,  1899,  LXXIV,  673. 

6  Arch,  of  Pediat.,  1906,  XXVII,  923. 


Fig.  2. 


Fir,.  3. 


Fic.  4. 


Fig.  0.3. — The  Patiiognomoxic  Sign  of  Measles  (Koplik'.s  Spots). 

Fig.  1. — The  di.scrctc  mca.slcs  spots  on  the  buccal  or  lahial  mucous  membrane,  sho.vinc  the 
isolated  roso-rcd  spot,  with  the  minute  bluish-white  centre,  on  the  normallj^  colored  nuicous 
membrane. 

Fig.  2. — Shows  the  jKirtially  dilTuse  erui)tion  on  tiic  mucous  menilTane  of  the  cheeks  and 
lips;  patches  of  pale  pink  interspersed  among  rose-red  patches,  tiie  hitter  showing  numerous 
pale  bluish-whitc!  spots. 

Fi(i.  8. — The  ajipearancc?  of  the  bucrtal  or  labial  mucous  membrane  wlien  the  measles  spots 
completely  coalesce  and  give  a  diffuse  redness,  witli  the  m>-ria(ls  of  lihiish-white  specks.  The 
exanthema  on  the  skin  is  at  this  time  generally  fully  developed. 

Fi(i.  4. — .\phtlious  stomatitis  apt  to  be  mistaken  for  measles  spots.      Mucous  membrane 
normal  in  line.     Minute  yellow  points  are  surrounded  by  a  red  area.     Always  tliscrete. 
(Medical  Xcws,  I.SOO,  Ixxiv,  (17:5.) 


MEASLES 


341 


remaining,  repeated,  careful  inspection  will  fail  to  reveal  it.  It  dis- 
appears by  the  time,  or  eyen  before,  the  cutaneous  eruption  is  fully 
developed. 

Prodromal  cutaneous  eruptions  are  not  infrequently  observed  in 
this  stage,  if  not  seen  earlier.  Thus  from  a  number  of  hours  up  to  a  day 
or  more  before  the  characteristic  eruption  is  distinctly  visible,  there  can 
sometimes  be  observed  an  alteration  in  the  appearance  of  the  skin  of  the 
face,  suggesting  a  roughness,  reddening  or  mottUng  situated,  as  it  were, 
beneath  the  surface.  In  other  cases 
there  is  a  distinct  localized  blotchy 
erythema  or  an  urticaria,  or  a  more  or 
less  widely  diffused  scarlatiniform  rash, 
or  even  a  faint  eruption  which  suggests 
the  beginning  of  the  ordinary  rash. 
These  prodromal  eruptions  are,  in  my 
experience,  common.  They  usually  dis- 
appear before  the  true  exanthem  of  the 
disease  becomes  manifest. 

All  the  catarrhal  symptoms  are  well 
marked  by  the  2d  day  of  invasion,  and 
increase  steadily  in  severity  through 
this  stage.  The  temperature  curve 
during  this  period  is  subject  to  varia- 
tions. Verv  frequently  it  increases 
steadily  to  102°  to  104°F.  (38.9°  to40°C.), 
with  ordinary  morning  remissions  (Fig. 
64).  In  very  many  cases,  however, 
after  a  sharp  initial  rise  there  occurs 
about  the  2d  or  3d  day  a  decided 
remission  or  even  intermission  of  both 
evening  and  morning  temperature,  fol- 
lowed by  the  redevelopment  of  fever 
before  the  eruption  appears  (Fig.  65). 
Occasionally  the  cutaneous  eruption  be- 
gins to  develop  before  the  temperature 
rises  again  (Fig.  66).  This  fall  of  tem- 
perature is  entirely  unattended  by  any 
amelioration  in  the  other  symptoms. 
It  has  been  considered  by  many  writers 
to  be  characteristic  of  the  disease. 
Others  maintain  that  the  curve  without 
intermission  occurs  as  frequently  as  the 
other,  and  this  has  been  my  own  ex- 
perience.    Bolognini^   describes   a   very 

obtained  by  palpation  of  the  abdomen  during  the  stage  of  invasion.  His 
observations  are  confirmed  by  Koppen.^  The  duration  of  the  stage  of 
invasion  in  typical  cases  is  3  or  4  days.  Irregularity  in  its  duration  and 
course  will  be  referred  to  later  (p.  345). 

Period  of  Eruption. — The  Rash. — The  characteristic  rash  is  found  on 
the  skin  by  the  end  of  the  3d  or  the  morning  of  llie  4tii  day  of  the  disease 
in  ordinary  cases;  sometimes  not  until  the  5th  day.  It  develops  first 
either  upon  the  forehead,  scalp,  cheeks,  temples,  beliind  the  ears,  or  about 

iLa  Pediat.,  1895,  III,  110. 

2  Centralbl.  f.  inn.  Med.,  1898,  XIX,  673. 


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Fig.  66. — Measles  with  Pre- 
ERUPTivE  Fall  of  Temperature 
Continuing  when  Rash  First 
Appeared. 

Howard  M.,  aged  7  years.  Jan.  25, 
catarrhal  symptoms  and  fever;  Jan.  26, 
temperature  falling;  Jan.  27,  abundant 
eruption  on  face,  spreading  to  body, 
temperature  still  afebrile;  Jan.  30, 
rash  almost  gone,  temperature  still 
elevated;  Jan.  31,  desquamation. 

slight  sensation  of  crepitation 


342 


THE  DISEASES  OF  CHILDREN 


the  mouth;  the  exact  situation  probably  varying  with  the  case.  It 
then  spreads  with  variable  rapidity,  but  as  a  rule  is  not  only  more  abun- 
dant by  its  2d  day  in  the  regions  where  first  seen,  but  has  extended  over 
the  whole  body,  possibly  excepting  the  legs  and  forearms,  feet  and  hands, 
which  may  not  be  involved  until  its  3d  day.  Even  the  palms  and  soles 
finally  exhibit  it.  The  individual  spots  are  at  first  of  small  pin-head  size, 
pale-red,  not  elevated,  round  or  irregular  in  shape,  and  discrete  with  the 


Fig.  67. — Eruption  of  Measles. 
Boy  of  12  years,  showing  the  characteristic  grouping  exhibited  by  the  eruption. 


surrounding  skin  healthy.  They  rapidly  enlarge  up  to  the  size  of  a  large 
split  pea,  become  distinctly  elevated  to  sight  and  touch  and  of  a  darker  red 
color,  commonly  with  a  slightly  bluish  cast.  There  exists  a  decided 
tendency  to  grouping,  a  series  of  spots  becoming  confluent  by  their 
margins  into  irregular,  short,  straight  or  curved  lines — the  well-known 
"crescentic  eruption"  (Fig.  67).  These  groupings  are  separated  by  small 
white  channels  of  healthy  skin,  the  contrast  producing  the  appearance 
characteristic  of  this  disease.  In  some  portions  of  the  body,  especially 
the  face,  back,  buttocks  and  the  inner  surface  of  the  thighs,  the  rash 
may  become  confluent  in  large  areas,  the  intervening  channels  disap- 


MEASLES 


343 


pearing  to  a  large  extent.     Even  here,  however,  the  pecuHar  uneven 
roughness  and  lack  of  uniformity  in  coloring  are  quite  evident. 

The  individual  spots  reach  their  fullest  development  in  about  24  hours, 
and  then  begin  to  fade.  Pressure  by  the  finger  will  at  first  completely 
obliterate  them  for  a  moment ;  later  a  slight  discoloration  remains.  Taken 
as  a  whole  the  rash  is  at  its  height  on  the  2d  or  3d  day  of  the  eruptive 
period  and  then  fades,  beginning  in  the  situation  where  it  first  arppeared. 
It  may  consequently  be  diminishing  on  the  face  while  not  yet  at  its 
height  upon  the  legs.     All  traces  of  the  eruption  have  disappeared  by  the 


Fig.  68. — Facies  in  Measles. 
Girl  with  measles,  showing  the  peculiar  heavy  and  swollen  appearance  of  the  face. 

4th  or  5th  daj'  after  the  first  appearance,  except  a  pale-yellowish  or  l)rown- 
ish  pigmentation  which  very  commonly  persists  for  a  decidedly  longer 
time. 

Other  Symptoms  of  (he  Eruptive  Stage. — The  fever  gonerally  in- 
creases with  the  development  of  the  rash  and  reaches  its  maximum  with 
this  upon  the  2d  or  3d  day  of  the  eruptive  stage,  with  only  sliglit  morn- 
ing remissions.  There  are,  however,  very  many  exceptions  to  this  rule, 
and  it  is  of  frequent  occurrence  foi*  the  temperature  to  fall  almost  by  crisis 
even  upon  the  2d  day  of  this  stage,  while  the  rash  is  still  at  its  height, 
or  even  before  it  has  attained  this.  All  the  catarrhal  symptoms  mean- 
while persist  or  increase  in  severity  as  the  rash  develops.  On  the  2d 
day  of  the  rash  there  is  present  a  very  decided  puffiness  of  the  face, 
which,  with  the  photophobia,  conjunctivitis,  severe  coryza,  obstructed 


344  THE  DISEASES  OF  CHILDREN 

nasal  respiration,  and  excoriation  of  the  upper  lip  give  to  the  child  a  very 
characteristically  stupid  expression  (Fig.  68).  The  ej'^es  secrete  freely, 
and  the  edges  of  the  lids  stick  together  during  sleep.  The  voice  is  hoarse, 
cough  is  often  distressing,  and  numerous  rales  can  generally  be  heard  in 
the  chest.  The  tongue  is  coated,  and  in  severe  attacks  may  become  dry 
or  even  denuded.  The  inflammation  of  the  fauces  and  pharynx  continues 
but  is  seldom  very  severe.  Thirst  is  great,  the  appetite  is  lost,  and  diar- 
rhea is  a  frequent  and  sometimes  troublesome  symptom.  Vomiting 
is  not  common.  There  may  be  slight  delirium  during  the  height  of  the 
attack,  or  the  drowsiness  of  the  prodromal  stage  may  persist.  The  super- 
ficial lymphatic  glands  throughout  the  body  are  swollen  and  often  tender. 
As  I  have  pointed  out  elsewhere^  this  enlargement  is  quite  commonly 
so  considerable  that  its  well-recognized  occurrence  in  rubella  as  well 
cannot  be  considered  so  diagnostic  a  symptom  of  the  latter  disease  as 
is  often  supposed.  There  is  often  very  annoying  itching  of  the  skin. 
Febrile  albuminuria  sometimes  occurs,  there  is  a  marked  diazo-reaction, 
diacetic  acid  and  propeptone  may  sometimes  be  found  in  the  urine,  and  a 
moderate  urobilinuria  is  present  (Rach  and  Reuss).^ 

The  blood  was  studied  by  Renaud^  and  since  then  by  Flesch  and 
Schossberger,*  Hecker,^  Lucas^  and  others.  There  may  be  a  transient 
lymphocytosis  early  in  the  incubation,  but  from  2  to  6  days  before  the 
first  symptoms  appear,  there  occurs  a  leucopenia  with  a  very  character- 
istic relative  diminution  or  even  disappearance  of  the  lymphocytes,  the 
blood-picture  showing  a  predominance  of  polymorphonuclear  cells.  This 
diminution  of  the  lymphocytes  shows  itself  several  days  before  the  de- 
velopment of  the  buccal  eruption.  During  invasion  the  number  of 
polymorphonuclear  cells  becomes  diminished  in  uncomplicated  cases 
both  relatively  and  absolutely,  and  the  blood-picture  again  becomes 
lymphocytic.  A  hypoleucocytosis,  especially  of  the  polymorphonuclear 
cells  with  increase  of  the  mononuclear  cells  is  very  decided  in,  and  quite 
characteristic  of,  the  early  eruptive  stage.  The  eosinophiles  are  di- 
minished in  number.  The  normal  number  of  leucocytes  is  soon  attained 
as  convalescence  advances.  Hyperleucocytosis  develops  if  complications 
are  present. 

When  the  rash  begins  to  fade  on  the  2d  or  3d  day  of  the  eruptive 
period,  the  temperature,  if  still  elevated,  falls  rapidly  by  lysis,  often 
reaching  normal  in  1  or  2  days  after  the  fall  begins.  The  catarrhal 
symptoms  also  improve  rapidly,  keeping  pace  with  the  temperature, 
although  hoarseness,  cough,  and  irritation  of  the  eyes  frequently  last  for 
several  days  longer.  The  average  duration  of  fever  is  about  7  days 'in 
all,  but  often  less.  (See  Figs.  65  and  66.)  The  frequency  of  respiration 
and  pulse  is  in  proportion  to  the  elevation  of  temperature,  unless  com- 
plications appear.  The  rapidity  of  the  disappearance  of  the  symptoms 
is  generally  very  striking. 

Period  of  Desquamation. — The  eruptive  and  desquamative  stages 
cannot  be  very  sharply  demarcated.  As  a  rule,  the  stage  of  desquama- 
tion may  be  said  to  begin  with  the  disappearance  of  the  eruption,  not  in- 
cluding the  pigmentation,  and  with  the  subsidence  of  other  symptoms  on 

1  Univ.  Med.  Mag.,  1892,  June. 

2  Zeitschr.  f.  Kinderh.,  Orig.,  1911,  II,  460. 

3  These  de  Lausanne,  1900.     Ref.  v.  Jiirgensen.  Nothnagel's  Encyclop.  Amer.  Med. 
Measles,  335. 

'  Jahrb.  f.  Kinderh.,  1906,  LXIV,  724. 
5  Zeitschr.  f.  Kinderh.,  Orig.,  1911,  II,  77. 
«  Amer.  Journ.  Dis.  Child.,  1914,  VII,  149. 


MEASLES  345 

the  7th  or  8th  day  of  the  disease,  although  the  actual  scaling  may  not 
appear  until  1  or  several  days  later.  The  desquamation  consists  of 
very  fine,  branny  scales.  As  a  rule  it  is  found  first  on  the  face  and  later 
elsewhere,  following  the  order  in  which  the  eruption  made  its  appearance. 
It  continues  a  few  days  to  a  week,  or  occasionally  longer.  The  amount 
of  desquamation  is  usually  in  proportion  to  the  intensity  of  the  eruption; 
but  although  sometimes  extensive  and  very  noticeable,  it  is  generally 
slight  and  most  evident  on  the  face,  and  in  many  cases  cannot  be  detected 
at  all.  There  are  no  symptoms  characteristic  of  this  stage,  except  in 
some  cases  a  persistence  of  the  catarrhal  manifestations,  especially  the 
cough  and  the  conjunctival  irritation. 

Variations  from  the  Ordinary  Type. — Many  variations  from  the 
type  described  may  mark  the  attack  either  as  a  whole  or  in  certain 
particulars. 

The  duration  of  incubation  may  be  altered,  but  a  stage  of  less  than  8 
days  or  more  than  12  days  is  unusual.  As  short  a  duration  as  5  days 
and  as  long  as  3  weeks  are  on  record.  Occasionally  symptoms  are 
observed  consisting  of  loss  of  appetite,  slight  fever,  malaise,  and  perhaps 
slight  indications  of  the  catarrhal  condition  to  follow.  Exceptionally 
other  symptoms  appear  during  this  period,  but  such  are  to  be  regarded 
as  accidental  or  anomalous. 

The  stage  of  invasion  may  be  unusually  protracted,  lasting  perhaps 
6  to  8  days.  Barthez^  reports  an  instance  of  invasion  continuing  16 
days.  It  is,  however,  more  prone  to  be  abnormally  short,  lasting  only  1 
to  2  days,  and  sometimes  there  appears  to  be  no  period  of  invasion  what- 
ever. I  have  seen  entire  local  epidemics  of  measles  in  institutions  charac- 
terized b}^  an  absence  or  very  shght  development  of  prodromer.  The 
combined  length  of  incubation  and  invasion  is  fairly  constantly  14  days. 
If,  then,  one  of  these  periods  is  lengthened  or  shortened,  the  other  must 
vary  inversely  with  it.  There  are,  of  course,  exceptions  in  which  the 
total  duration  of  the  two  periods  is  shorter  or  longer  than  the  figure 
given.  In  other  cases  the  initial  symptoms  may  be  unusually  intense; 
stupor,  convulsions,  continuously  high  fever  and  severe  diarrhea  or 
vomiting  being  among  these.  The  respiratory  symptoms  may  be  ex- 
cessive, the  secretion  from  the  eyes  and  noso  being  profuse,  and  the 
breathing  difficult,  or  croup  may  complicate  the  condition.  Violent 
epistaxis  may  occur,  or  other  complications  may  influence  the  character 
of  this  stage.  In  one  instance  under  my  own  ol)servation  a  well-marked 
lobar  pneumonia  represented  the  chief  of  the  symptoms  of  invasion. 
This  was  followed  at  the  proper  time  by  the  development  of  the  erup- 
tion and  of  other  evidences  of  measles,  while  the  pneumonia  meanwhile 
underwent  rapid  resolution.  Bronchopneumonia  is  also  reported  as 
a  prodromal  symptom.  These  unusually  severe  initial  symptoms 
may  continue  into  the  eruptive  stage,  or  may  ameliorate  when  the 
eruption  appears. 

The  eruptive  stage  is  also  subject  to  numerous  variations,  giving  dis- 
tinct types  to  the  attack.  First  is  to  be  mentioned  thi>  mild  form.  In 
this  the  child  is  so  little  ill  that  it  is  not  confined  to  bed.  and  sutlers  jirac- 
tically  no  discomfort.  After  a  short  invasion  the  catarrhal  symptoms 
continue  to  be  of  very  mild  cliaractcM-  and  the  fever  is  only  slight,  or  even 
entirely  absent  (Rubeola  afebrUis)  (Fig.  ()9).     The  eruption  is  often  pale- 

1  Barthez  and  Sann6,  Malad.  des  enf.,  1S91,  III,  17. 


346 


THE  DISEASES  OF  CHILDREN 


red,  scanty  and  very  little  confluent,  strongly  suggesting  rubella,  or  so 
poorly  developed  that  diagnosis  is  very  difficult. 

An  abortive  form  is  characterized  by  a  well-marked  stage  of  invasion, 
but  with  an  eruptive  stage  which,  sometimes  typical  at  the  onset,  some- 
times poorly  developed,  rapidly  disappears  together  with  the  attending 
symptoms  (Fig.  70).     Measles  without  eruption  (Rubeola  sine  eruptione) 


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Fig.  71. 


Fig.  69. — Rubeola  Afebbilis. 
Richard  G.,  aged  8  years.     Apr.  15,  vomited,  lachrymation;  Apr.  16,  vomited  again, 
characteristic  rash  after  a  mustard-bath,  mild    catarrhal  symptoms  throughout  attack, 
no  fever  during  eruptive  period,  and  no  indication  of  it  earlier. 

Fig.  70. — Abortive  Measles. 
Frank  A.,  aged  4  years.     Apr.  29,  for  3  days  had  coughing,  sneezing  and  drowsiness, 
typical  eruption  appeared  today  on  face,  catarrhal  symptoms  continue;  Apr.  30,  rash  spread 
yesterday,  now  fading;  May  1,  rash  nearly  disappeared. 

Fig.  71. — Rubeola  sine  Catarrho. 
Willie  B.,  aged  10  years.     Apr.  18,  no  symptoms  noted;  Apr.  19,  no  catarrhal  symptoms 
except  a  very  slight  redness  of  the  eyes,  eruption  developing;  Apr.  20,  eruption  more 
abundant,  no  catarrhal  symptoms  whatever;  Apr.  21,  rash  fading.     House  epidemic. 


has  been  described,  catarrhal  symptoms  being  present  unattended  by 
rash.  Embden^  reports  20  instances  in  one  epidemic  of  461  cases.  So, 
too,  cases  are  observed  in  which  the  characteristic  rash  occurs  but  with- 
out catarrhal  symptoms  (Rubeola  sine  catarrho)  (Fig.  71).  It  is  almost 
certain  that  the  great  majority  of  the  cases  apparently  of  this  variety 
are  instances  of  rubella  or  some  disorder  of  the  skin.  Only  in  house 
epidemics  could  the  diagnosis  of  either  of  these  two  forms  be  made,  and 
then  only  with  great  reserve. 

1  Inaug.  Dissertat.  Heidelberg,  1889. 


MEASLES 


347 


The  severe  forms  of  measles,  apart  from  the  influence  of  complications, 
may  be  of  several  varieties,  although  no  sharp  line  of  distinction  separates 
one  from  another.  In  one,  which  may  be  called  the  prolonged  type,  the 
fever  lasts  an  unusually  long  time.  This,  as  a  rule,  depends  upon  the 
persistence  of  catarrhal  symptoms,  and  especially  upon  a  more  than 
ordinary  degree  of  bronchitis.  In  other  severe  cases  the  virulence  of  the 
poison  is  very  great.  All  the  symptoms  exhibit  an  unusual  severitj' 
ffom  the  outset,  the  eruption  being  very  intense,  widespread,  confluent, 
and  of  a  dusky,  blue-red  color.     In  other  instances  the  disease  begins 


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Fig.  73. 


Fig.  72. — Malignant  Measles. 
Robert    McD.,    aged    16   months.     June    14,   vomiting,    purging,    fever,    convulsions, 
said  to  have  had  fever  several  days,  older  brother  convalescent  from  measles;  June  15, 
faint  macular  rash  after  hot  bath,  convulsions  and   unconsciousness  continued,  hydren- 
cephalic  cry,  death  in  evening  of  the  1st  day  of  the  eruption. 

Fig.  73. — Hemorrhagic  Measles. 
Willie  P.,  aged  5  years.     Jan.  30,  catarrhal  symptoms  noted;  Jan.  31,  severe  chill, 
cyanosis,  unconsciousness,  wcll-devclopcd  rash  folU)\ved  hot  bath;  Feb.  3,  been  growing 
steadily  worse,  tongue  dry,  delirium;  Feb.  4,  eyes  sunken,  crowded  petechia;  on  abdomen, 
larger  purpuric  patches  on  legs.     Death, 

in  the  ordinary  way,  but  soon  assumes  a  severe  type.  In  still  others 
some  of  the  symptoms  are  but  little  marked.  This  is  especially  true  of 
the  rash,  which  may  be  poorly  developed  throughout  the  attack  and 
frequently  late  in  appearing,  or  which  often  shows  a  remarkable  tend- 
ency to  repeated  disappearance,  even  when  brought  temporarily  into 
evidence  by  hot  baths  ("Retrocession  of  the  eruption").  It  was  long 
erroneously  supposed  that  this  "striking  in  of  the  rash"  was  the  cause 
of  the  unfavorable  symptoms.  It  is,  however,  only  an  evidence  of  the 
feebleness  of  the  circulation.     Many  of  these  cases  with  retrocession 


348  THE  DISEASES  OF  CHILDREN 

assume  what  has  been  called  the  typhoid  form.  The  rash  is  then  at  no 
time  well  developed,  there  is  great  prostration,  dry  tongue,  rapid  and 
weak  pulse,  rapid  respiration,  high  temperature,  low  delirium,  restless- 
ness, twitching,  and  perhaps  repeated  convulsions. 

The  most  severe  type  of  the  disease  is  the  malignant  form.  The 
symptoms  are  even  more  severe  than  those  described,  the  course  of  the 
disease  rapid,  and  death  may  take  place  before  the  time  is  reached  for 
the  eruption  to  appear  (Fig.  72).  The  temperature  in  some  of  these 
severe  cases  may  reach  108°  to  109°F.  (62.2°  to  62.7°C.).  The  hemor- 
rhagic type,  or  "black  measles"  of  the  older  writers,  is  another  severe 
type,  really  a  malignant  variety,  less  often  seen  than  formerly.  It  occurs 
only  in  subjects  already  much  debilitated.  The  rash  is  pale  and  never 
well  developed.  Hemorrhages  take  place  into  the  spots  and  elsewhere 
into  the  skin  as  well  as  into  the  muscles  and  from  the  mucous  mem- 
brane.    There  is  dehrium  and  great  prostration  (Fig.  73). 

There  are  a  number  of  minor  variations  from  the  ordinary  type 
depending  upon  characteristics  of  the  eruption,  none  of  them  possessing 
any  special  significance.  Sometimes  the  rash  appears  upon  the  trunk 
before  it  does  upon  the  face.  Infrequently  the  macules  are  very  small 
and  so  closely  placed  that  the  rash  of  scarlet  fever  is  simulated.  In 
some  mild  cases  the  rash  appears  only  upon  some  one  part  of  the  body, 
especially  the  face  and  neck.  In  Morhilli  papulosi  the  eruption  consists 
of  large,  deep-red  spots  more  papular  than  usual.  Morhilli  miliares 
exhibits  minute  vesicles  upon  the  usual  eruption.  A  Morhilli  hullosi 
has  also  been  described,  although  rarely  seen,  an  eruption  resembling 
pemphigus  replacing  or  being  combined  with  the  ordinary  rash  of  measles. 
The  term,  Ecchymotic  m,easles  is  well  applied  to  the  cases  so  frequently 
seen  in  which  extravasation  of  blood  or  of  blood-coloring  matter  has 
taken  place  into  the  rash,  especially  on  the  extremities.  The.  deep-red- 
dish-purple markings  thus  produced  are  uninfluenced  by  pressure,  and 
remain  distinct  for  days  or  even  weeks  after  all  other  symptoms  of  the 
disease,  except  desquamation,  have  disappeared.  To  call  this  form 
"hemorrhagic  measles"  as  is  sometimes  done,  is  a  source  of  confusion, 
since  there  are  none  of  the  grave  symptoms  present  which  characterize 
the  latter  affection. 

Complications  and  Sequels.^ — ^The  younger  the  child  the  more 
frequent  and  more  serious  are  the  complications  and  sequels  liable  to 
be.  After  early  childhood  they  are  comparatively  uncommon.  Most 
important  and  oftenest  seen  are  those  connected  Math  the  respiratory 
tract.  Exceptionally  epistaxis  may  be  so  severe  or  so  often  repeated  that 
it  becomes  an  important  complication.  Chronic  nasal  discharge  may  be 
a  sequel.  Catarrhal  laryngitis  is  always  present  to  some  extent  and  may 
at  times  be  attended  by  so  much  mucous  secretion,  spasm  or  edema  that 
severe  laryngeal  stenosis  develops  and  even  death  may  occur.  When  the 
stenosis  depends  on  the  first  two  factors  it  is  intermittent;  whqn  on  the 
last  it  is  more  or  less  constantly  present.  Stenosis  is  always  a  dangerous 
complication  unless  of  very  short  duration.  Ulcerative  laryngitis  is  a 
not  uncommon  complication  or  sequel.  Membranous  laryngitis  may  be 
due  to  the  presence  of  either  a  streptococcus  or  of  the  diphtheria  bacillus. 
(See  Vol.  II,  pp.  21  and  449.)  The  first  occurs  oftenest  early  in  the  attack, 
the  second  at  a  later  period.  The  symptoms  are  much  the  same  and  a  posi- 
tive diagnosis  can  be  made  only  by  bacteriological  examination.  Gannelon^ 
found  membranous  laryngitis  in  14.4  per  cent,  of  1633  cases  of  measles. 
^La  rougeole  a  Thospice  des  enfants  assist6es,  1892. 


MEASLES  349 

A  subglottic  laryngitis  may  occur  and  cause  great  disturbance  of  respira- 
tion, and  even  death,  no  membrane  being  discoverable. 

Trachitis  and  bronchitis  belong  to  the  regular  symptoms  of  the  disease. 
The  latter  may  sometimes  become  so  severe  that  it  prolongs  the  fever 
decidedly  and  may  then  be  looked  upon  as  a  sequel. 

Bronchopneumonia,  frequently  tuberculous,  is  very  common  espe- 
cially in  infancy  and  early  childhood  and  is  always  most  serious.  It  may 
develop  at  any  time  in  the  course  of  the  disease,  but  oftenest  during  the 
eruptive  stage  or  as  a  sequel  after  a  short  intermission.  The  statistics 
regarding  the  frequency  of  the  occurrence  of  bronchopneumonia  vary 
considerably.  Jtirgensen^  found  them  ranging  from  6  per  cent,  to  16  per 
cent,  of  the  cases  of  measles. 

Croupous  pneumonia  is  a  much  less  common  complication,  but  is 
occasionally  seen.  Gangrene  of  the  lung  and  pleurisy  with  effusion  are 
observed  exceptionally  and  bronchiectasis  has  been  recorded  as  a  sequel. 

The  gastroenteric  tract  likewise  furnishes  many  complications  and  se- 
quels. Some  degree  of  catarrhal  stomatitis  is  one  of  the  regular  symp- 
toms of  the  disease.  Aphthous  and  ulcerative  stomatitis  are  frequently 
seen.  Gangrenous  stomatitis  is  rare,  yet  measles  perhaps  more  than  any 
other  disease  predisposes  to  it.  Membranous  pharyngitis  is  not  un- 
common, patches  developing  on  the  tonsils  and  adjacent  parts.  Like 
membranous  laryngitis,  with  which  it  is  often  combined,  it  may  be  strepto- 
coccic or  trulj'^  diphtheritic  in  nature.  Diarrhea  is  not  infrequently 
sufficiently  severe  to  constitute  a  complication.  Oftener  it  continues  as 
a  sequel,  sometimes  in  a  very  chronic  form.  It  may  be  simpty  catarrhal 
in  nature,  or  may  depend  upon  ileocolitis.  This  latter  is  especially  liable 
to  develop  in  summer  time  in  debilitated  subjects  under  2  years  of  age. 
Le  Lyonnais-  collected  18  instances  of  appendicitis  occurring  as  a  sequel 
to  measles. 

Otitis  is  of  frequent  occurrence,  varying  with  the  epidemic.  In  a 
mild  non-suppurative  form,  it  is  very  common  in  the  early  part  of  the 
eruptive  stage.  In  a  more  severe  form,  with  pain,  suppuration  and 
fever,  it  occurs  oftener  as  a  sequel  about  the  end  of  the  2d  week.  Both 
ears  are  then  usually  affected,  permanent  injury  may  result,  or  menin- 
gitis may  follow.  Of  501  cases  of  chronic  disease  of  the  middle  ear  pub- 
lished by  Downie''  26.1  per  cent,  owed  their  origin  to  measles.  Yet 
as  a  rule  chronic  otitis  follows  much  less  often  than  after  scarlet  fever. 

Inflammation  of  the  eyes  of  various  sorts  is  often  observed  with  or  after 
the  attack.  Catarrhal  conjunctivitis  is  one  of  the  symptoms  of  the  dis- 
ease and  can  be  considered  a  complication  only  when  unusually  severe. 
It  is  frequently  very  persistent  in  poorly  nourished  children.  Keratitis 
and  iritis  may  occur  as  sequels  and  optic  neuritis  is  occasionally  seen, 
Griscom''  having  collected  23  cases  in  addition  to  1  reported  by  him. 

Circulatory  affections  are  uncommon.  Endocarditis,  pericarditis  and 
myocarditis  are  rarely  seen.  Thrombosis  of  the  vessels  in  different  parts 
of  the  body  may  exceptionally  occur  (Leitz).*  In  the  extremities  this  may 
produce  gangrene  of  the  limij.  Sioelliny  of  the  thyroid  gland  Iims  boon 
reported.  (Jf  gcnifo-urinary  complications  nephritis  is  generally  con- 
sidered unusual.     I  have,  however,  seen  it  not  infrequently  either  with 

'  Nothnagcl's  Kncvclop.  Amer.  Ed.,  318. 

■  Thftse  do  Paris,  i'Jl.i-U,  IS'o.  109.     Kef.  Brit.  Jour.  Cliil.l.   Dis.,  1914,  XI,  234. 

3  Brit.  Med.  .lourn.,  1894,  II.  1163. 

*  Ann.  of  Ophthalm.,  1912,  XXI,  42. 

5  Berl.  klin.  Woch.,  1913,  L,  15(30. 


350  THE  DISEASES  OF  CHILDREN 

the  attack  or  later.  Acute  degenerative  lesions  of  the  kidney  develop 
in  malignant  cases.  Pyelitis  may  occur.  Ulcerous  vulvitis  and  gan- 
grene of  the  vulva  are  very  rare  sequels,  to  which,  however,  measles 
especially  predisposes. 

Affections  of  the  hones  and  skin  have  been  reported  as  compli- 
cations, among  them  gangrene,  herpes  zoster,  herpes  labialis,  urticaria, 
erythema,  and  furunculosis.  Osteomyelitis  and  necrosis  have  been  re- 
corded. Arthritis  is  a  very  uncommon  sequel.  Generalized  cutaneous 
emphysema  has  been  reported. 

Nervous  affections  are  unusual.  Meningitis  occurs  occasionally  as 
a  sequel  to  otitis,  or  dependent  upon  a  complicating  tuberculosis.  A 
dull  apathetic  condition  is  exceptionally  seen,  lasting  for  weeks  after 
the  disease  is  over.  I  have  observed  it  in  1  instance.  In  2000  cases 
of  imbecility  Beach"^  found  11  which  dated  from  an  attack  of  measles. 
Chorea  and  epilepsy  have  been  reported  as  sequels  and  tetany  has  been 
occasionally  observed  during  the  attack.  Convulsions  sometimes  develop 
during  the  attack  and  then  constitute  a  very  unfavorable  indica- 
tion. Paralysis  of  various  forms  may  follow  measles.  It  may  be  cere- 
bral, myelopathic  or  peripheral  in  nature.  The  subject  has  been  reviewed 
by  Allyn,2  Briickner,^  and  others. 

Other  infectious  diseases  may  exist  in  conjunction  with  measles,  or 
as  sequels  or  predecessors  to  it.  One  of  the  most  common  and  unfavor- 
able combinations  is  that  of  measles  and  diphtheria,  the  latter  being'prone 
to  develop  during  the  convalescent  stage  of  the  former.  In  3400  cases  in 
the  Medical  Asylums  Board's  Hospitals  (Rolleston)^  2.10  per  cent,  de- 
veloped diphtheria.  Scarlet  fever  and  measles  often  occur  together,  or 
one  immediately  after  the  other.  The  combination  of  varicella,  ery- 
sipelas, vaccinia,  grippe,  or  typhoid  fever  with  measles  is  occasionally 
seen,  or  the  immediate  following  or  preceding  of  the  latter  by  one  of  the 
others.  Epidemics  of  pertussis  are  particularly  liable  to  precede  or  follow 
or  to  prevail  at  the  same  time  with  epidemics  of  measles.  Measles,  too, 
is  certainly  very  prone  to  be  followed  closely  by  evidences  of  tuberculosis 
or,  if  the  latter  disease  has  already  manifested  itself,  to  increase  its  further 
development.  Very  many  of  the  cases  of  bronchopneumonia  attending 
measles  are  tuberculous  in  nature,  and  osseous  and  glandular  tuberculosis 
are  frequent  sequels.  For  some  reason  there  is  often  a  temporary  in- 
susceptibihty  to  the  tubercuHn  reaction  during  the  occurrence  of  an 
attack  of  measles. 

Relapse. — This  is  encountered  usually  with  great  rarity,  although 
Leade^  observed  it  4  times  in  an  epidemic  of  262  cases.  Undoubtedly 
many  reported  instances  are  errors  in  diagnosis.  It  takes  place  in  from 
the  2d  to  the  4th  week  or  sometimes  later,  after  the  attack  is  apparently 
over  but  while  the  original  infection  is  still  present  in  the  system.  It 
consists  in  the  return  of  some  or  all  of  the  characteristic  symptoms 
of  the  disease.  The  mere  re-development  of  some  one  symptom  during 
the  attack,  as,  for  instance,  the  reappearance  of  the  rash,  does  not  con- 
stitute a  relapse.  As  a  rule  the  relapse  is  less  severe  and  of  shorter  dura- 
tion than  the  first  attack. 

Recurrence. — In  spite  of  the  widespread  belief  among  the  laity  to 
the  contrary,  second  attacks  of  measles  are  of  very  great  rarity.     This 

1  Brit.  Med.  Journ.,  1895,  II,  707. 

2  Med.  News,  1891,  LIX,  617. 

3  jahrb.  f.  Kinderheilk.,  1902,  LVI,  725. 
*  Brit.  Jour.  Child.  Dis.,  1915,  XII,  21. 
5  Lancet,  1905,  II,  1837. 


MEASLES  351 

is  the  opinion  of  the  majority  of  authorities.  INIost  instances  of  so-called 
recurrence  are  instances  of  errors  in  diagnosis,  which  circumstances 
make  particularly  easy  in  this  disease.  ^Maiselis^  collected  only  21  cases 
from  medical  literature,  while  he  found  154  of  scarlet  fever.  In  1100 
cases  of  the  disease  Widowitz^  observed  no  instance  of  a  second  attack. 

Prognosis. — The  prognosis  of  measles  is  generally  good,  the  mor- 
tality averaging  from  3  to  6  per  cent.,  often  less,  but  sometimes  reaching 
much  higher  figures.  During  5  years  there  occurred  in  Philadelphia 
50,715  cases  of  measles,  with  a  mortality  of  1.6  per  cent.  (Graham).^  The 
number  of  cases  of  measles  is,  however,  so  great  that  the  number  of  deaths 
from  it  is  large.  Comby*  gives  20,518  fatal  cases  in  Paris  during  19  years 
and  McCollum^  states  that  the  deaths  during  5  years  in  London  per 
10,000  of  the  population  were  3  or  4  times  more  numerous  from  measles 
than  from  scarlet  fever.  The  greatest  number  of  fatalities  is  observed 
in  the  2d  week  of  the  attack. 

Many  factors  influence  the  mortality.  That  of  the  epidemic  is  one 
of  the  most  noteworthy  of  these,  the  disease  being  much  more  fatal  in 
some  years  than  in  others.  At  times  under  unfavorable  conditions 
the  death-rate  has  exceeded  30  per  cent,  of  the  cases,  while  at  other 
times  it  does  not  reach  2  per  cent.  In  1914  in  170,004  cases  of  measles 
occurring  in  portions  of  the  United  States  the  mortality  was  1.73  per 
cent.  (Wilson).^  Age,  also,  exercises  a  powerful  influence.  In  general 
the  younger  the  patient  attacked  during  infancy  and  childhood  the  graver 
the  prognosis,  and  the  number  of  fatal  cases  is  very  much  diminished 
after  the  5th  year.  The  disease  appears  to  be  milder  and  the  mortality 
less  in  the  first  6  months  than  in  the  succeeding  months  of  the  1st  j^ear. 
Variof  found  a  mortality  of  12.31  per  cent,  among  601  cases  of  the  dis- 
ease in  children.  In  the  1st  year  the  mortality  was  32.72  per  cent,  and 
in  the  2d  year  29  per  cent.  The  greatest  actual  number  of  deaths 
occurred  in  the  2d  year,  there  being  fewer  cases  of  the  disease  in  the  1st. 
Of  367,602  deaths  from  measles  reported  in  England  and  Wales  during 
40  years  335,874  were  in  children  under  5  years  of  age  (Williams).^ 
Henoch's^  statistics  for  the  Charite  Hospital  gave  a  mortality  of  55.6  per 
cent,  in  the  first  2  years  of  life  and  9.3  per  cent,  for  from  3  to  11  years.  In 
some  epidemics,  however,  the  mortality  has  been  notably  high  among 
adults.  This  was  the  case  in  the  Faroes'  epidemic  of  1845  (Panumi"), 
and  Kilbourne^^  reported  a  severe  epidemic  of  600  cases  occurring  in 
barracks  with  a  mortality  of  5  per  cent. 

Debilitating  influences,  such  as  want,  exposure,  crowding,  imperfect 
hygiene  in  general,  and  neglect  of  treatment,  increase  the  death-rate 
greatly.  It  is  probably  such  factors  which  have  caused  the  high  mortality 
in  foundling  asylums  and  other  institutions  for  infants  and  children, 
and  among  soldiers  in  camps.  The  proportion  of  fatal  cases  among  the 
poor  in  institutions  is  always  much  higher  than  in  private  practice  among 
the  better  classes.     Of  1575  children  treated  during  5  years  in  the  Hospice 

1  Virchow's  Archiv,  1894,  CXXXVII,  468. 

2  Wien.  klin.  Wochenschr.,  1909,  XXII,  1596. 

3  Jour.  Amer.  Med.  Assoc,  1917,  LXVII,  1272. 
*  Traite  des  mal.  do  I'l-nf.,  2d  ed..  Ill  347. 

5  Bost.  Med.  and  Surg.  .Journ.,  190.3,  CXLVIII,  31. 
8  Arch,  of  Pediat.,  1916,  XXXIII,  261. 
'  Bull,  de  la  .soc.  de  pc-diat.,  1904,  No.  1. 

8  20th  Cent.  Pract.  of  Med.,  XIV,  120. 

9  Rof.  Williams,  loc.  cit.,  121. 
^"^  Loc.  cit.,  292. 

"  Mil.  Surgeon,  1912,  XXXI,  294. 


352  THE  DISEASES  OF  CHILDREN 

des  Enfants-Assistes  in  Paris,  728  died;  i.e.  46.22  per  cent  (Comby).^ 
Rolleston^  reported  a  mortality  of  12.6  per  cent,  in  3400  cases  in  the 
Metropolitan  Asylums  Board's  Hospitals  in  1913,  most  of  the  children 
being  of  the  poorer  classes. 

Complications  and  sequels  are  far  oftener  the  cause  of  death  than  is 
the  disease  itself.  So,  too,  the  occurrence  of  measles  as  a  secondary 
affection  to  other  diseases  adds  greatly  to  the  danger.  Bronchopneu- 
monia, tuberculous  or  otherwise,  perhaps  occasions  more  deaths  than  any 
other  complicating  affection,  but  diphtheria  and  diarrhea  are  the  factors 
in  many  instances.  Of  157  cases  of  the  combination  of  measles  and 
diphtheria  published  by  Blakely  and  Burrows'*  34  per  cent.  died.  Even 
after  the  disease  seems  completely  over,  death  often  results  from  the 
development  of  fatal  sequels,  especially  tuberculosis. 

Certain  unfavorable  symptoms  may  be  referred  to.  A  high  tem- 
perature during  invasion  indicates  that  the  attack  will  probably  be  a 
severe  one.  A  poorly  developed  eruption  or  one  which  retrocedes 
readily,  combined  with  marked  general  symptoms,  is  of  unfavorable 
import.  High  fever  persisting  w^hile  the  other  symptoms  are  disap- 
pearing suggests  the  presence  of  some  complication.  The  development 
of  unusual  hoarseness  may  denote  the  existence  of  severe  laryngitis. 

Diagnosis.- — The  diagnosis  of  measles,  although  generally  easy  in 
the  eruptive  period,  is  sometimes  attended  by  great  difficulty.  It 
rests  principally  upon  the  long  prodromal  stage  with  the  attending  fever 
and  catarrhal  symptoms,  and  the  development  later  of  the  characteristic 
eruption.  In  the  stage  of  invasion  the  resemblance  of  the  catarrhal 
symptoms  to  those  of  a  severe  cold  is  Yery  close.  The  fever  is  perhaps 
unduly  high  for  the  latter  condition,  and  the  symptoms  in  general  too 
severe;  yet  positive  diagnosis  at  this  stage  would  be  impossible  were 
it  not  for  the  presence  of  the  spots  upon  the  palate,  and  especially  of  the 
characteristic  buccal  eruption.  Very  exceptionally  the  latter  has  been 
reported  present  in  pertussis  and  folhcular  tonsillitis  (Michelazzi)^  and 
in  rubella  (Widowitz;^  Miiller).^ 

Yet  since  few  observers  claim  to  have  seen  it  in  any  other  disease 
than  measles,  the  presence  of  the  buccal  eruption  is  a  very  valuable 
diagnostic  sign.  Its  absence,  however,  is  not  proof  that  the  disease 
is  not  measles.  The  diminution  of  the  lymphocytes  is  of  diagnostic  value 
during  incubation,  the  relative  increase  of  polymorphonuclear  cells 
then  distinguishing  measles  from  the  first  stage  of  pertussis,  in  which 
there  is  an  increase  of  the  lymphocytes  (Renaud).^  The  neutrophilic 
hypoleucocytosis  and  the  diminution  of  the  number  of  the  eosinophiles 
are  a  diagnostic  aid  in  the  eruptive  stage,  being  exactly  the  opposite  of 
the  condition  seen  in  scarlet  fever. 

Rubella  is  the  disease  which  resembles  measles  most  closely.  The 
chief  points  of  distinction  are  the  shortness  and  mildness  or  absence  of 
prodromes  in  rubella;  the  slight  degree  of  catarrhal  symptoms;  and  the 
more  rapid  development  of  the  eruption,  its  absence  of  grouping,  and 
its  more  multiform,  paler  and  fugacious  character.  The  degree  of 
glandular  enlargement  is  of  little  aid  in  diagnosis.     (See  Rubella.)     Yet 

1  Trait6  des  malad.  de  I'enf.,  2d  ed.,  Ill,  348. 

2  Brit.  .Jour.  Child.  Dis.,  1915,  XII,  129. 

3  Bost.  Med.  and  Surg.  Journ.,  1901,  CXLV,  89. 
*  Gaz.  degli.  osp.  a  delle  clin.,  1904,  XXV,  35. 

6  Wien.  klin.  Wochenschr.,  1899,  XII,  919. 
6  Munch,  nied.  Wochenschr.,  1904,  LI,  98. 
'  These  de  Lausanne,  1900. 


MEASLES  353 

in  some  atypical  cases  of  rubella  the  rash  is  characteristically  morbilli- 
form in  character,  and  the  catarrhal  symptoms  are  marked,  while  in 
some  instances  of  measles  the  symptoms,  including  the  eruption,  are 
poorly  developed  and  strongly  suggest  rubella.  In  sporadic  cases  of 
measles  the  diagnosis  is  consequently  often  impossible  unless  the  buccal 
eruption  is  discovered. 

Scarlet  fever  can  cause  difficulty  only  in  atypical  cases.  Such  cases 
sometimes  exhibit  a  very  blotchy  rash  somewhat  resembling  measles, 
while,  on  the  other  hand,  the  rash  of  measles  may  at  times  be  so  con- 
fluent that  scarlet  fever  is  suggested.  Careful  examination  will,  however, 
show  decided  differences  in  the  two  eruptions.  That  of  measles  is  always 
slightly  uneven  to  the  touch  and  areas  or  channels  of  healthy  white 
skin  can  always  be  found  in  some  localities.  The  chin  and  the  region 
about  the  mouth  are  free  from  eruption  in  scarlet  fever  and  always  in- 
volved in  measles.  There  is  moreover  in  scarlet  fever  the  more  sudden 
onset,  decided  sore  throat,  often  initial  vomiting,  and  the  absence  of 
catarrhal  symptoms.  The  desquamation  in  the  two  affections  is  entirely 
different  in  character. 

Grippe  of  the  respiratory  type  may  closely  resemble  the  initial  stage  of 
measles.  There  is,  however,  less  photophobia.  The  development  of 
the  characteristic  rash  in  measles,  or,  even  before  this,  of  the  buccal 
eruption,  will  settle  the  diagnosis.  Typhoid  fever  occasionally  exhibits 
a  rash  so  abundant  that  that  of  measles  is  strongly  suggested.  I  have 
occasionally  seen  such  cases.  (See  p.  395,  Fig.  93.)  The  diseases  have 
however,  no  other  symptoms  in  common.  The  rash  of  typhus  fever  may 
be  much  like  that  of  measles  and  catarrhal  symptoms  attend  the  pro- 
dromal stage.  Other  symptoms,  however,  differ  entirely.  Severe  and 
rapidly  fatal  cases  of  cerebrospinal  fever  may  resemble  malignant  measles. 
Both  possess  the  sudden  development  of  threatening  cerebral  symptoms, 
while  ill-defined  eruptions  with  a  hemorrhagic  tendency  may  be  present 
in  either.  I  have  known  of  several  instances  where  the  diagnosis  between 
these  two  diseases  could  not  be  determined  with  certainty.  The  eruption 
of  variola  may  at  first  resemble  measles  with  an  unusually  papular  rash. 
The  error  fortunately  is  usually  that  of  considering  measles  to  be  small- 
pox. The  diagnosis  is  generally  soon  apparent.  The  initial  stage  of 
variola  is  totally  different,  being  marked  by  headache,  vomiting  and  pain 
in  the  back,  without  catarrhal  symptoms,  while  the  rash  is  more  papular 
and  shot-like  than  that  of  measles.  It  is  possible,  too,  for  the  prodromal 
rash  of  variola  to  resemble  the  eruption  of  measles  to  some  extent. 
Vaccinia  occasionally  exhibits  a  morbilliform  erythema.  It  has,  however, 
no  other  symptoms  suggesting  measles.  Varicella  can  scarcely  be  a 
source  of  confusion.  The  eruption  could  simulate  that  of  measles  only 
at  the  onset.  The  roseola  of  syphilis  may  resemble  the  rash  of  measles 
closely.     Other  symptoms,  however,  are  lacking. 

Various  eruptions,  not  symptoms  of  infectious  fevers,  may  have  a 
close  resemblance  to  measles.  Notable  among  these  are  some  of  the 
erythemata,  especially  the  medicamentous  rashes,  among  these  being 
those  produced  by  antipyrine,  copaiba,  cubebs  and  chloral.  That 
following  the  administration  of  diphtheria-antitoxin  occasionally  awakens 
suspicion.  In  none  of  these  are  other  ruboolous  symptoms  present. 
They  may,  however,  lead  to  errors  in  diagnosis.  This  is  especially  true 
if  coryza  happens  to  coexist.  Urticaria,  too,  may  exhibit  at  times  a  very 
morbilliform  eruption.  The  absence  of  other  symptoms  ami  the  gen- 
eral history  of  the  attack  are  usually  conclusive. 

23 


354  THE  DISEASES  OF  CHILDREN 

Treatment.  Prophylaxis.  Quarantine. — Although  measles  is  gen- 
erally a  mild  disease,  yet  the  inability  to  predict  the  outcome  in  any  given 
case  necessitates  the  employment  of  all  prophylactic  measures  possible. 
Especially  are  3^oung  children  and  those  in  a  debilitated  condition  to  be 
protected  from  it.  Unfortunately  the  ease  and  frequency  with  which  it  is 
communicated  before  its  existence  is  suspected  render  these  measures 
frequently  of  no  avail.  Other  children  of  the  family  who  have  been  in 
contact  with  an  affected  child  during  the  state  of  invasion  have  probably 
already  contracted  the  disease.  Still,  as  it  may  chance  that  infection 
may  not  yet  have  occurred,  isolation  should  be  established  imme- 
diately, and  maintained  until  all  danger  of  infecting  others  is  over.  The 
appearance  of  the  hypolymphocytosis  during  incubation  can  be  made  use 
of  effectively  in  epidemics  to  enforce  prompt  isolation  of  the  patient.  In 
the  absence  of  entire  certainty  regarding  the  duration  of  infectiousness 
quarantine  should  continue  for  at  least  2  weeks  from  the  onset,  or  longer 
if  there  has  been  a  persistence  of  nasal  or  aural  discharge.  Other  non- 
immune children  who  have  been  exposed  should  be  kept  from  intercourse 
with  susceptible  playmates  for  14  days  in  order  to  permit  the  usual  period 
of  incubation  to  elapse.  It  must  be  recognized,  however,  that  the  im- 
probability of  the  disease  being  transmitted  by  a  third  person  renders 
immune  children  of  no  danger  to  others,  even  if  they  have  been  associa- 
ting with  the  patients.  If  the  germ,  as  already  stated,  does  not  live 
longer  than  2  weeks  from  the  onset  of  the  attack,  disinfection  of  the  room 
after  the  disease  is  not  imperative,  provided  it  is  thoroughly  cleansed  and 
aired.  There  is  no  necessity,  too,  of  destroying  books,  toys  and  the  like. 
However,  disinfection  can  do  no  harm,  and  is  an  additional  precautionary 
measure.  So,  too,  it  is  wise  to  allow  the  room  to  be  unoccupied  by  non- 
immune persons  for  a  week  or  more  after  the  patient  is  removed  from  it. 
Other  susceptible  children  of  the  family  need  not  necessarily  be  sent 
from  the  house.  They  are  not  likely  to  contract  the  disease  after  isola- 
tion is  established. 

Protective  treatment  by  inoculation  hsis  been  tried  by  Home, ^  Thomson,"^ 
Herman^  and  others  with  the  purpose  of  preventing  or  of  mitigating  the 
attack.     The  success  has  not  as  yet  been  sufficient  to  be  convincing. 

Treatment  of  the  Attack. — In  average  uncomplicated  cases  very  little 
treatment  of  any  kind  is  required  and,  in  any  event,  is  purely  sympto- 
matic. The  choice  and  management  of  the  sick-room,  and  the  method 
of  conducting  quarantine  and  nursing  are  described  in  the  introductory 
remarks  under  Infectious  Diseases  (p.  306).  There  is  particular  need 
of  an  abundance  of  fresh  air  without  exposure  in  this  disease,  since  the 
tendency  to  the  development  of  bronchopneumonia  is  certainly  checked 
in  this  way.  The  air  should  be  somewhat  moist,  and  the  temperature 
of  the  room  may  well  be  rather  higher  than  for  certain  other  diseases, 
owing  to  the  existence  of  catarrhal  symptoms.  The  eyes  should  be 
carefully  guarded  from  undue  exposure  to  light,  but  without  making  the 
room  nearly  dark  as  is  often  done.  The  sensations  of  the  patient  are  the 
best  guide  in  this  respect.  These  can  be  determined  in  young  subjects 
by  careful  observation.  Shielding  the  eyes  by  a  screen  is  often  a  great 
relief.  The  patient  should  be  confined  to  bed  while  fever  lasts  and  should 
be  lightly  covered.  The  head  must  not  be  kept  too  low,  as  this  often 
tends  to  increase  the  amount  of  cough.     The  diet  should  be  light,  milk 

^Loc.  cit. 

2  Glasgow  Med.  Journ.,  1890,  XXXITI,  420. 

3  Arch,  of  Pediat.,  1915,  XXXII,  503. 


MEASLES  355 

being  one  of  the  most  serviceable  foods.  Such  cereals  as  oatmeal  are  to 
be  avoided  on  account  of  the  possibility  of  exciting  the  diarrhea  to  which 
the  disease  predisposes. 

The  patient  should  receive  ablution  daily,  exposure  being  carefully 
avoided.  Daily  examinations  of  the  mouth,  nose  and  throat  ought  to 
be  made  in  order  to  discover  the  onset  of  any  complication  here. 

Further  treatment  of  some  of  the  individual  symptoms  may  be  con- 
sidered more  in  detail. 

Fever  in  ordinary  cases  may  be  combated  by  such  simple  febrifuges 
as  potassium  citrate  or  spirits  of  nitrous  ether,  in  some  cases  with  the 
addition  of  small  amounts  of  tincture  of  aconite  root.  A  warm  tub  bath 
is  often  of  great  benefit.  If  the  temperature  is  unusually  high  and  is 
unrelieved  by  these  measures,  antipyrine  or  phenacetin  may  be  employed, 
small  repeated  doses  being  given  rather  than  larger  single  ones.  These 
drugs  are,  however,  seldom  required.  The  mere  occurrence  of  a  tempera- 
ture of  104°F.  (40°C.)  at  the  height  of  the  disease,  unattended  by  any 
unfavorable  symptoms,  does  not  demand  energetic  treatment.  The  con- 
tinued application  of  an  ice  cap  to  the  head  is  often  serviceable.  Occa- 
sionally in  obstinate  and  threatening  hyperp3^rexia  the  cool  pack  or  cool 
tubbing  is  of  value,  unless  general  cyanosis  or  coldness  of  the  extremities 
shows  the  existence  of  cardiac  weakness.  It  must  be  remembered  that 
children  often  bear  the  application  of  cold  water  or  ice  badly. 

Nervous  symptoms,  such  as  headache,  unusual  restlessness,  grinding  of 
the  teeth,  stupor,  impending  convulsions  and  the  like,  are  benefited  by 
some  bromide  salt,  and,  still  more,  by  warm  tub-baths,  phenacetin,  or 
antipyrine  given  as  described. 

Constipation  may  be  relieved  by  enemata.  Purgatives  should,  as  a 
rule,  be  avoided  on  account  of  their  tendency  to  act  too  freely  in  this 
disease. 

Diarrhea  generally  requires  no  medication  in  ordinary  cases  in  healthy 
subjects.  If  at  all  severe,  or  if  the  child  is  debilitated,  it  must  be  promptly 
checked  with  bismuth,  sulphuric  acid,  or  tannic  acid  preparations  with 
or  without  opium. 

Vomiting  seldom  needs  other  treatment  than  temporary  rest  of  the 
stomach  with  careful  selection  of  the  diet. 

Irritation  of  the  eyes  demands  the  protection  from  light  referred  to. 
In  addition  there  should  be  frequent  douching  with  a  tepid  solution  of 
boric  acid.  Rubbing  the  edges  of  the  lids  with  petrolatum  prevents  their 
adhesion  during  sleep.  Cold  wet  cloths  applied  to  the  eyes  and  changed 
every  few  minutes  are  serviceable  when  inflammation  is  severe.  Pro- 
tection and  treatment  of  the  eyes  must  be  continued  during  convalescence 
until  the  irritation  has  disappeared. 

Inflammation  of  the  throat  and  nose  may  well  be  treated  by  spraying 
with  an  alkaline  antiseptic,  such  as  liquor  sodii  boratis  conip.  (r)ol)eirs 
solution)  diluted,  or  with  a  mentholated  oily  spray  (menthol  2  grains, 
liquid  petrolatum  1  oz.)  (0.13;  30).  The  systematic  employment  of 
this  procedure  probably  lessens  the  chances  of  the  development  of 
diphtheria,  as  well  as  of  pneumonia  through  the  extension  of  germs 
to  the  lungs.  The  distressing  coiujh  requires  snuiU  repeated  doses  of 
deodorized  tincture  of  opium,  or,  in  older  ciiihhen,  of  heroin  or  codeine, 
enough  being  given  to  produce  some  result.  When  bronchitis  is  severe, 
the  chest  being  full  of  small  mucus  rales  and  dyspnea  present,  the  appli- 
cation of  mustard  poultices,  or  even  of  dry  cups  may  be  helpful.  Fre- 
quently repeated  warm  tub  baths  are  often  beneficial,  and  l)elhulonna  is 


356  THE  DISEASES  OF  CHILDREN 

also  useful  in  this  connection.  The  patient  should  be  propped  up  well  in 
bed,  as  this  renders  respiration  easier.  Pneumonia  should  be  guarded 
against  by  the  careful  avoidance  of  all  exposure,  especially  after  fever  has 
disappeared,  the  supply  of  an  abundance  of  warm,  fresh,  moist  air,  the 
rigorous  confinement  of  the  child  to  bed,  the  control  of  bronchitis,  and 
the  use  of  a  nasal  and  pharyngeal  spray.  It  is  also  advisable  not  to 
keep  subjects  with  measles  and  bronchopneumonia  in  the  same  room 
with  other  patients  suffering  from  measles  alone,  as  the  pulmonary  con- 
dition tends  to  spread  to  the  latter. 

Cardiac  or  general  debility  calls  for  the  use  of  alcoholic  or  other  stimu- 
lants. The  hot  mustard  tub  bath  is  of  especial  service  in  the  cases  where 
retrocession  of  the  rash  shows  the  weakness  of  the  heart.  The  develop- 
ment of  otitis  may  be  hindered  by  the  use  of  the  antiseptic  spraying  of 
the  nose  and  throat  referred  to,  combined  with  the  constant  wearing  of 
a  flannel  cap  over  the  ears. 

Itching  of  the  skin  is  relieved  by  the  frequent  application  of  a  powder 
consisting  of  camphor  1  dr.  (3.9) ;  zincmn  oxidum  ^2  oz.  (15.5);  amylum 
}'2  oz.  (15.5)  or  of  a  2  per  cent,  carbolized  petrolatum.  In  the  case  of 
young  children  a  1  per  cent,  thymolated  petrolatum  is  safer. 

Alore  detailed  treatment  of  the  various  complications  referred  to, 
as  well  as  of  others  not  mentioned  in  this  connection,  will  be  found  de- 
scribed in  discussing  these  diseases.  It  may  be  remarked,  however,  that 
the  frequency  with  which  diphtheria  associates  itself  with  measles  in 
institutions,  and  with  which  germs  resembling  the  Klebs-Loeffler  bacillus 
are  found  on  the  mucous  membrane  of  cases  of  measles,  even  though 
without  suspicious  symptoms,  justifies  the  preventative  inoculation  with 
antidiphtheritic  serum  which  has  been  recommended. 

During  convalescence  the  diet  may  be  increased,  but  confinement  to  bed 
should  continue,  except  in  the  mildest  cases,  for  at  least  10  days  from 
the  beginning  of  the  stage  of  invasion ;  certainly  for  several  days  after  fever 
has  disappeared;  and  to  the  room  for  2^^^  to  3  weeks.  The  eyes  often 
require  careful  protection  for  some  time,  and  the  bronchitis  which  fre- 
quently persists  may  need  appropriate  treatment.  Before  leaving  the 
sick-room  a  disinfectant  bath  may  well  be  given  (p.  243).  Owing  to  the 
sensitiveness  of  the  mucous  membranes  the  first  outing  should  be  in  good 
weather  and  the  patient  carefully  protected.  Tonics  are  often  required 
at  this  period,  among  the  most  useful  being  iron,  cod  liver  oil  and  strych- 
nine. If  health  is  not  rapidly  regained,  a  complete  change  of  air  to  a 
warm,  dry  region  is  advisable,  owing  to  the  tendency  to  the  develop- 
ment of  tuberculosis  as  a  sequel. 


CHAPTER  IV 

RUBELLA 

(German  Measles) 

The  disease  has  very  numerous  synonyms.  The  term  Rubella 
was  first  employed  by  Veale^  and  appears  to  be  that  most  suited  to  it. 
"Rotheln,"  a  title  formerly  often  applied  to  it  is  a  foreign  word,  and  there 
is  no  need  for  its  employment  in  English-speaking  countries. 

For  many  years  the  disease  had  been  confounded  with  measles  and  with 
scarlet  fever,  but  its  independence  is  now  fully  recognized.  It  is  probably 
the  mildest  of  the  acute  infectious  fevers.  The  first  clear  description  of 
1  Edin.  Med.  Jour.,  1866,  404. 


RUBELLA  357 

its  symptoms  as  we  now  know  them  was  given  by  Heim^  in  Germany  and 
by  Maton^  in  England.  Much  earUer  than  this  accounts  were  published 
of  an  affection  claimed  to  be  distinct  from  measles,  yet  clearly  much 
more  severe  than,  and  different  materially  in  many  respects  from,  rubella 
as  seen  at  the  present  day. 

Etiology.  Predisposing  Causes. — Among  these  age  is  important. 
The  disease  is  most  common  between  the  ages  of  5  and  15  years,  yet 
adults  are  frequently  attacked,  and  F.  Seitz^  reports  an  instance  in  a 
woman  of  73  years.  Among  664  cases  collected  by  J.  Seitz^  45  (7  per 
cent.)  were  adults.  Whether  adults  possess  a  relatively  lesser  degree 
of  susceptibility  is  uncertain,  although  it  has  seemed  to  me  probable. 
Satisfactory  data  are  lacking  on  this  point.  Infants,  especially  under  the 
age  of  6  months,  are  much  less  frequently  attacked. 

Sex,  race,  and  climate  are  not  etiological  factors.  Epidemic  influence 
is  particularly  marked,  the  disease  being  unusual,  even  in  large  cities, 
except  in  certain  years  when  extensive  epidemics  occur.  Season  is  not 
without  influence,  most  epidemics  appearing  in  winter  and  spring.  Con- 
cerning the  individual  susceptibility  there  is  a  difference  of  opinion.  Some 
regard  the  disease  as  only  mildly  contagious,  many  persons  seeming  im- 
mune. My  own  experience  is  that  it  is  decidedly  contagious,  although 
less  so  than  measles,  and  that  a  large  proportion  of  children  exposed  will 
contract  it.  Older  subjects,  as  stated,  probably  possess  a  greater  degree 
of  immunity. 

Exciting  Cause.^ — -This  is  undoubtedly  a  germ,  but  its  nature  is  entirely 
unknown.  Transmission  is  probably  by  way  of  the  secretion  from  the 
eyes  and  the  oral  and  respiratory  mucous  membranes,  and  possibly  in 
the  scales  of  the  epidermis,  although  the  latter  is  doubtful.  Indirect 
infection  through  a  third  person,  clothing,  and  the  like,  is  perhaps  possi- 
ble, but  certainly  very  unusual.  Transmission  by  the  air  probably  occurs 
to  a  very  limited  extent.  Hess^  attempted  to  transmit  the  disease  to 
apes  without  success. 

The  period  of  greatest  infectiousness  is  unknown.  The  disease  is, 
without  doubt,  infectious  during  the  stages  of  eruption  and  of  invasion, 
and  it  seems  likely  during  the  latter  part  of  incubation,  but  probably 
ceases  to  be  so  with  the  disappearance  of  the  rash.  Exact  data  are 
lacking  regarding  the  infectiousness  during  desquamation.  It  is  doubt- 
ful whether  it  exists. 

Pathological  Anatomy. — There  are  no  lesions  characteristic  of  the 
disease.  The  eruption  appears  to  depend  upon  a  capillary  hyperemia 
of  the  upper  layers  of  the  corium  with  slight  inflammatory  exudate 
(Thomas).^     More  exact  studies  have  not  been  made. 

Symptoms.  Ordinary  Course.  Period  of  Incubation. — One  of 
the  features  of  the  disease  is  the  variability  of  this  period.  The  average 
range  would  appear  to  be  from  1  to  3  weeks,  although  I  have  seen  it  as 
short  as  5  days.''     There  are  no  symptoms  characteristic  of  this  stage. 

Period  of  Invasion. — In  the  great  majority  of  cases  prodromal  symp- 
toms are  either  absent  or  so  insignificant  that  they  arc  overlooked. 
They  usually  consist  of  slight  cough,  sneezing,  mild  congestion  of  the 

1  Hufclancls  Journal,  1812,  III,  01. 

2  Med.  Transact.  Col.  of  Phys.,  Lond.,  1815,  V,  149. 
»  Bayrisch.  iirztl.  Intelligcnzbl.,  1873,  XX,  TfiO. 

*  Correspondbl.  f.  Schweiz.,  Aerzte.,  1890,  XX. 

5  Arch,  of  Int.  Med.,  1914,  XIII,  913. 

"  Ziemssen's  Handb.  spec.  Path.-anat.  u.  Thcrap.,  B.  II,  H.  II,  128. 

^  N.  Y.  Med.  Rec,  1887,  July  2  and  9. 


358  THE  DISEASES  OF  CHILDREN 

mucous  membrane  of  the  nose  and  eyes,  drowsiness,  malaise,  enlarge- 
ment of  the  superficial  cervical  glands  and  sometimes  slight  fever.  These 
last  generally  not  more  than  12  to  24  hours  or  less. 

Period  of  Eruption.  Rash. — Commonly  without  warning  the  child  on 
waking  in  the  morning  is  found  to  be  covered  by  the  characteristic  rash. 
This  appears,  as  a  rule,  first  upon  the  face  and  spreads  very  rapidly  over 
the  body,  covering  it  within  a  few  hours  or  a  day,  and  involving  sometimes 
the  soles  and  the  palms.  It  consists  of  irregularly  shaped,  pale-rose  spots, 
slightly  elevated  both  to  sight  and  to  touch,  and  varjdng  in  size  from  an 
ordinary  pin-head  up  to  a  split-pea.  The  spots  are  more  or  less  closely 
placed,  but  not  arranged  in  groups  as  in  measles.  They  are  for  the  most 
part  discrete,  but  often  show  decided  confluence  on  the  face  and  on  re- 
gions pressed  upon  and  kept  warm  in  bed,  such  as  the  nates  and  the 
flexor  surfaces  of  the  thighs.  On  the  trunk  the  rash  is  usually  paler 
than  elsewhere  and  of  a  slightly  brownish-red  color.  Very  commonly 
the  eruption  passes  rapidly  like  a  wave  over  the  body,  having  almost  faded 
from  the  face,  neck,  and  trunk  by  the  time  the  full  development  is  reached 
on  the  extremities  12  to  24  hours  later;  the  acme  on  any  one  part  lasting 
only  from  a  few  hours  to  half  a  day.  This  has  been  considered  a  charac- 
teristic of  the  disease.  Nearly,  or  fully  as  often,  however,  in  my  experi- 
ence, the  eruption  reaches  its  fullest  development  everywhere  on  the  2d 
day,  after  which  it  fades  with  great  rapidity.  The  total  duration  of  the 
rash  upon  the  body  equals  2  to  4  days,  although  it  often  lasts  a  much 
shorter  time. 

Other  Sympioms  of  the  Eruptive  Stage. — Appearing  with  the  erup- 
tion, or  continuing  in  an  accentuated  form  from  the  stage  of  invasion, 
when  this  is  discoverable,  are  the  trifling  symptoms  of  the  eruptive  stage. 
They  consist  of  moderate  redness  of  the  eyes,  occasionally  sneezing,  sore 
throat,  and  slight  hoarseness  and  cough.  Decided  coryza  is  absent. 
Often  there  are  no  catarrhal  symptoms  whatever,  except  the  moderate 
affection  of  the  throat,  which  is  one  of  the  most  characteristic  and  con- 
stant symptoms.  Sometimes  this  is  not  complained  of,  but  on  inspection 
the  mucous  membrane  of  the  pharynx  exhibits  a  diffuse  redness,  and  the 
tonsils  are  generally  swollen.  In  a  considerable  number  of  cases  an  erup- 
tion of  yellowish-red  or  brownish-red  spots  (enanthem),  of  pin-head 
size,  is  visible  over  the  soft  palate,  the  uvula,  and  the  mucous  lining  of 
the  cheeks.  This  appears  simultaneously  with  the  rash  upon  the  skin 
and  lasts  about  half  a  day.  Widowitz^  claims  to  have  found  the  buccal 
eruption  of  measles  in  10  out  of  135  cases  of  rubella  (7.41  per  cent.), 
and  Miiller^  has  also  seen  it  repeatedly.  The  experience  of  observers 
in  general  does  not  corroborate  this  statement.  I  have  seen  1  instance 
in  which  I  believed  it  to  be  present.  Occasionally,  the  cough  and  sore 
throat  continue  longer  than  the  cutaneous  eruption.  Elevation  of  tem- 
perature is  generally  slight  or  absent.  It  reaches  its  maximum  on  the 
1st  or  2d  day  of  the  eruptive  stage,  and  either  falls  suddenly  while 
the  rash  is  still  at  its  height  or  diminishes  more  slowly  as  this  fades.  The 
fever  seldom  exceeds  101°  to  102°F.  (38.3°  to  38.9°C.).  Not  infrequently 
a  subfebrile  temperature  persists  for  some  days  after  the  rash  has  dis- 
appeared. The  tongue  is  clean  or  slightly  coated;  never  "strawberry"  as 
in  scarlet  fever.  Enlargement  of  the  superficial  cervical  and  posterior 
auricular  glands  is  nearly  always  present  and  very  characteristic,  and 
often  continues  after  the  rash  has  disappeared.     It  is  not,  however,  as 

1  Wiener  klin.  Wochenschr.,  1889,  XII,  919  . 

2  Munch,  med.  Wochenschr.,  1904,  LI,  98. 


RUBELLA  359 

diagnostic  as  once  supposed,  as  it  may  occur  in  measles  as  well.  Itching 
and  edema  are  cutaneous  manifestations  occasionally^  seen,  and  roughness 
of  the  skin  resembling  cutis  anserina  is  common.  The  bowel  movements 
and  urine  are  unaffected.  Vomiting  is  unusual.  The  condition  of  the 
blood  demands  further  study,  since  the  statements  are  somewhat  at  vari- 
ance. Hildebrant  and  Thomas^  found  an  increase  in  the  mononuclear 
cells  and  a  diminution  of  the  neutrophiles  most  marked  from  the  4th  to 
the  6th  day.  Spieler^  observed  an  increase  in  the  neutrophiles  during 
incubation  but  a  diminution  of  these  and  an  increase  of  the  lymphocytes 
in  the  stage  of  eruption,  the  condition  in  this  respect  resembling  that  seen 
in  measles.  Hess^  noted  definite  increase  of  the  number  of  lymphocytes 
before  the  eruptive  stage. 

The  duration  and  character  of  the  general  symptoms  are,  as  a  rule, 
proportionate  to  the  persistence  and  intensity  of  the  eruption,  but  to 
this  there  are  numerous  exceptions. 

Period  of  Desquamation. — Spots  of  a  faint  brownish  or  j^ellowish 
color  are  often  left  after  the  eruption  has  faded.  These  persist  2  or  3 
days.  A  faint,  branny  desquamation  resembling  that  of  measles  is 
very  common  but  by  no  means  always  present.  It  appears  shortly  after 
the  disappearance  of  the  eruption  and  continues  1  to  3  days. 

Variations  from  the  Ordinary  Form.^ — ^The  symptoms  just  de- 
scribed are  what  might  be  called  typical.  One  of  the  chief  characteristics 
of  rubella,  however,  is  its  tendency  to  variations,  many  of  which  occur 
so  frequently  that  they  cannot  be  called  unusual.  On  the  other  hand 
the  severe  epidemics  described  by  the  older  writers  and  by  a  few  more 
modern  ones  are  to  be  considered  as  entirely  anomalous. 

The  variable  length  of  incubation  is  a  normal  and  characteristic  ele- 
ment of  the  disease.  Epistaxis  and  sore  throat  have  been  reported  as 
occasionally  seen  in  this  period  (Squire).*  The  invasion  is  sometimes  un- 
usually prolonged.  I  have  known  it  to  last  48  hours,  and  periods  as  long 
as  6  or  7  days  have  been  reported.  All  such  prolongations  are  decidedly 
exceptional.  The  prodromal  symptoms  may  rarely  be  unusually  severe. 
Among  those  reported  are  decided  coryza,  vomiting,  convulsions, 
delirium,  bleeding  from  the  eyes,  ears  or  nose,  edema  of  the  face,  dizzi- 
ness, fainting,  severe  headache,  rigors,  croup,  and  various  cutaneous 
eruptions. 

The  eruption  is  extremely  prone  to  vary,  not  only  in  different  epidem- 
ics, but  in  different  cases  in  the  same  epidemic,  and  even  in  different 
parts  of  the  body  in  one  person.  In  fact,  this  multiform  character  is 
one  of  the  greatest  characteristics  of  the  disease.  Two  types  are  espe- 
cially noticeable,  which  are  best  designated  as  Rubella  moribillijormc  and 
Rubella  scarlatiniforme.  Both  must  be  considered  as  entirely  normal 
forms. 

In  Rubella  morbiliforme  the  spots  are  fully  the  size  of  a  split-pea 
and  deeper  colored  than  usual,  exhibiting  the  tint  of  measles  and  being 
often  characteristically  grouped  as  in  that  disease.  Such  a  rash  cannot 
be  distinguished  from  that  of  measles. 

In  Rubella  scarlatiniforme,  on  the  other  hand,  the  eruption,  at  first 
macular  and  discrete,  becomes  by  the  2d  day  widely  confluent  antl  is 
not  perceptibly  elevated.     Careful  examination   will  usually  reveal  a 

1  Zeit.  f.  klin.  Med.,  1906,  LIX,  444. 

2  Wien.  med.  Woch.,  1915,  LXV,  919. 

3  Loc.  cit.,  913. 

*  (plain's  Diet,  of  M(><1.,  Amcr.  Ed.,  1885,  1382. 


360 


THE  DISEASES  OF  CHILDREN 


few  macules  in  the  general  redness,  especially  on  the  brows,  wrists 
and  fingers.  Nevertheless,  in  many  cases  a  diagnosis  from  scarlatina, 
based  upon  the  eruption,  is  entirely  impossible,  especially  if  the  ease  was 
not  seen  at  the  onset.  Filatow^  believes  the  scarlatiniform  type  to  be  a 
distinct  disease  and  applies  to  it  the  older  German  title  "  Rubeola  scarla- 
tinosa." I  have,  however,  in  institution-epidemics  of  rubella,  observed 
some  children  with  an  eruption  exactly  simulating  measles,  and  others 


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Fig.  75. 


Fig.  74. — Rubella  Morbillifohme. 


Katie  G.,  aged  5  years.  Mar.  4,  lachrymation,  injection  of  eyes,  drowsiness,  twitching 
of  limbs,  red  throat,  numerous  discrete  pea-sized  macules  on  face;  Mar.  5,  rash  fading  from 
face,  abundant  on  body,  deep  red,  pea-sized,  grouped  as  in  measles  and  indistinguishable 
from  that  eruption,  child  brighter;  Mar.  6,  rash  fading  rapidly;  Mar.  7,  branny  desquama- 
tion beginning. 

Fig.  75. — Rubella  Scaelatinifoeme. 

Bertha  L.,  aged  8  years.  Mar.  6,  eyes  injected,  throat  red,  abundant  nearly  uniform 
eruption  over  Vjody  suggesting  scarlatina,  but  with  macules  visible  in  many  places;  Mar.  7, 
rash  indistinguishable  from  scarlet  fever  except  at  wrists  and  ankles,  throat  red;  Mar.  8, 
fading  rapidly,  macular  character  visible  on  legs,  throat  still  quite  red;  Mar.  9,  rash  prac- 
tically gone,  branny  desquamation  beginning. 


with  the  most  typical  rubella  scarlatiniforme.  All  gradations  may  be 
found  between  the  two  extremes.  Sometimes  the  rash  is  scarlatiniform 
in  some  regions  of  the  body  and  morbilliform  in  others.  In  general,  the 
more  elevated  the  rash,  the  greater  the  tendency  to  the  morbilliform 
type;  the  less  elevated,  the  more  disposition  to  confluence.  The  two 
illustrative  cases  (Figs.  74  and  75),  both  rather  severe,  illustrate  these  two 
forms  of  the  disease.  The  children  were  inmates  of  the  same  institution 
and  were  ill  at  the  same  time,  in  company  with  many  typical  cases  of 
the  malady. 

1  Arch.  f.  Kinderheilk.,  1885-6,  VII,  241. 


RUBELLA  361 

Other  peculiarities  of  the  rash  are  occasionally  seen.  Vesicles,  a 
purpuric  eruption,  a  marbled  appearance,  and  a  sensation  as  of  shot 
beneath  the  surface  have  been  reported.  I  have  seen  the  rash  first 
appear  as  annular  red  spots.  The  sequence  of  its  appearance  may  vary 
also,  the  trunk  or  the  arms  being  first  involved  in  some  cases.  Sometimes 
the  eruption  is  limited  to  a  certain  region,  especially  the  face  and  neck, 
lasting  but  a  few  hours  only.  It  is  probable  also  that  the  disease  may 
rarely  occur  without  eruption.  At  times  the  rash  nearly  disappears,  to 
reappear  after  a  brief  interval,  and  in  other  cases  there  seems  to  be  a 
true  retrocession  of  the  rash,  with  general  symptoms  more  severe  than 
usual. 

Considerable  variation  may  occur  in  the  symptoms  of  the  eruptive 
stage  other  than  the  rash.  The  catarrhal  manifestations  are  in  rare  in- 
stances as  marked  as  in  measles.  This  is  noticed  oftenest  in  the  rubeo- 
loid  type.  Decided  hoarseness  is  sometimes  present  and  cough  may 
occasionally  be  harassing.  The  tonsils  may  be  sufficiently  swollen  to 
make  deglutition  difficult  or  impossible,  and  sometimes  the  follicles  are 
engorged.  Exceptionally  the  temperature  may  reach  103°F.  (39.4°C.) 
or  over,  or  vomiting  may  be  severe.  Delirium  and  convulsions  have 
been  observed. 

The  desquamation  presents  nothing  varying  from  the  type,  except 
that  in  some  cases  it  is  usually  abundant  and  prolonged. 

Complications  and  Sequels. — These  occur  only  rarely.  Those 
oftenest  seen  are  in  connection  with  the  respiratory  tract.  Severe 
hronchitis  is  sometimes  witnessed,  and  pneumonia  may  occur  as  a  compU- 
cation  or  sequel.  I  have  seen  it  follow  in  2  instances.  Croup  and  pleu- 
risy have  been  reported.  Stomatitis  is  an  occasional  complication. 
Intestinal  catarrh  is  rare,  although  in  a  very  anomalous  severe  epidemic 
reported  by  Cuomo ^  it  was  witnessed  frequently.  A  secondary  sore 
throat  occurring  rarely  as  a  sequel  has  been  recorded  by  several  observers, 
and  albuminuria  and  nephritis  have  been  described  as  frequent  in  some 
entirely  anomalous  epidemics  (Ed wards), ^  but  ordinarily  are  most  un- 
usual. Arthritis  was  seen  by  Wichman^  in  18  out  of  75  cases,  and  fatal 
purpura  hsemorrhagica  by  Stratford.* 

Other  infectious  diseases  may  occasionally  be  associated  with  rubella 
as  complications  or  sequels.  Among  those  recorded  are  typhoid  fever, 
erysipelas,  varicella,  diphtheria  and  mumps.  Among  other  complica- 
tions and  sequels  reported,  generally  in  anomalous  cases,  are  thyroid 
enlargement,  conjunctivitis,  keratitis,  otitis,  endocarditis,  icterus,  urti- 
caria, temporary  paralysis,  and  abscesses  in  different  parts  of  the  body. 

Relapse  and  Recurrence. — Relapse  is  very  unusual.  Isolated 
cases  are  recorded  in  medical  literature.  It  occurred  3  times  in  150  cases 
which  I  have  previously  reported.^  It  is  oftenest  seen  from  1  to  3  weeks 
after  the  beginning  of  the  first  attack. 

Recurrence  is  rare,  one  attack  fully  protecting  from  another.  In 
363  cases  of  rubella,  Widowitz"  saw  recurrence  in  but  1  instance. 

Prognosis. — This  is  almost  invariably  good;  certainly  so  unless 
the  disease  has  assumed  an  entirely  anomalous  form.     Certain  epideni- 

1  Giorn.  internaz.  d.  scion,  mod.,  1884,  VI,  529. 

2  Anier.  Journ.  Med.  Sci.,  1884,  LXXXVIII,  448. 
»  Hospitalstidendo,  1898,  VI,  35. 

•  Lancet,  1911,  II,  156. 

•  Loc.  cit. 

•  Wien.  klin.  Wochcnschr.,  1909,  XXII,  159G. 


362  THE  DISEASES  OF  CHILDREN 

ics  have  been  reported,  especially  in  earlier  years,  where  the  mortality 
reached  from  5  to  9  per  cent.  All  such  occmTences  are,  however,  very 
unusual.  Death  has  generally  depended  upon  complications,  but  occa- 
sionally upon  the  depressing  effect  of  the  disease  itself.  I  have  never 
seen  a  fatal  case,  although  I  have  occasionally  seen  individuals  decidedly 
ill  with  the  disease. 

Diagnosis. — The  most  important  diagnostic  signs  are  the  variable 
duration  of  incubation,  the  short  or  absent  prodromes,  the  slight  degree 
of  catarrhal  symptoms  and  of  fever,  the  presence  of  sore  throat  and  en- 
larged superficial  cervical  glands,  and  the  characteristic  discrete  erup- 
tion. The  combination  of  the  last  with  insignificant  attendant  symp- 
toms is  very  suggestive  of  the  disease.  The  importance  of  a  correct 
diagnosis  is  great,  since  an  error  may  be  sufficient  to  spread  measles  or 
scarlet  fever  through  a  house  or  a  school.  Yet  owing  to  the  variability 
of  the  symptoms  this  is  seldom  easy  and,  in  sporadic  cases,  often  impos- 
sible. There  is  no  disease  of  which  it  is  more  true  that  the  diagnosis 
must  be  based  upon  the  study  of  the  entire  complex  of  symptoms. 

Mild  cases  of  measki<  resemble  rubella  very  closely.  The  longer  dura- 
tion and  greater  severity  of  the  prodromal  symptoms  in  measles  and 
the  buccal  eruption  will  be  valuable  diagnostic  aids.  Schick^  considers 
a  positive  tuberculin  test  evidence  of  rubella  as  against  measles.  A  nega- 
tive reaction  is  without  value.  It  is,  however,  the  distinguishing  of 
mild  scarlatina  from  the  scarlatiniform  type  of  rubella  which  is  especially 
difficult.  A  longer  period  of  incubation,  the  absence  of  vomiting,  and 
the  presence  of  slight  catarrhal  symptoms  with  but  moderate  sore  throat 
suggest  rubella;  but  the  most  important  diagnostic  symptoms  are  the 
presence  of  macules  somewhere  in  the  scarlatiniform  rash,  and  the  ab- 
sence of  any  approach  to  the  strawberry  tongue.  Later  the  differences 
in  the  desquamation  may  make  the  diagnosis  clear.  When  these  differ- 
ential symptoms  fail  to  render  a  decision  reasonably  certain,  the  only 
safe  plan,  with  regard  to  other  members  of  the  household,  is  to  make  the 
provisional  diagnosis  of  scarlet  fever.  When  an  epidemic  of  rubella  is 
prevailing  the  problem  is  a  much  simpler  one. 

Treatment.  Prophylaxis. — The  decided  contagiousness  of  rubella 
and  the  fact  that  it  is  communicated  to  others  even  before  it  is  recognized, 
render  prophylaxis  exceedingly  difficult.  In  view  of  this,  and  of  the  usual 
harmlessness  and  short  duration  of  the  affection,  it  is  questionable  whether 
isolation  is  worth  while,  if  only  the  diagnosis  has  been  made  with  certainty. 
The  inconvenience  attending  separation  of  the  sick  children  seems 
scarcely  warranted  by  the  insignificant  nature  of  the  disease.  If  it  is 
determined  to  institute  quarantine,  the  same  course  should  be  followed  as 
in  measles  and  probably  for  an  equal  length  of  time. 

Treatment  of  the  Attack. — This  is  purely  symptomatic  and  is,  indeed, 
seldom  needed.  The  patient  should  be  confined  to  bed  while  fever  lasts 
and  given  a  light  diet.  Of  course  should  the  individual  case  or  the  pre- 
vailing epidemic  be  unusually  severe,  more  energetic  measures  are  re- 
quired, both  prophylactic  and  after  the  attack  develops. 

1  Ergebn.  d.  inn.  Med.  u.  Ivinderh.,  1910,  V,  302. 


ERYTHEMA  INFECTIOSUM  363 


CHAPTER  V 

THE  FOURTH  DISEASE  AND  INFECTIOUS  ERYTHEMA 

THE  FOURTH  DISEASE 

(Filatow-Dnkes  Disease) 

In  1900  Dukes^  published  the  report  of  three  series  of  cases  which, 
he  beUeved,  showed  the  existence  of  a  fourth  eruptive  fever  in  addition 
to  measles,  scarlet  fever  and  rubella.  He  maintained  that  the  affection 
generally  believed  to  be  the  scarlatinifonn  type  of  rubella  was  in  reality 
a  distinct  disorder.  This  was  practically  the  view  advanced  by  Filatow^ 
in  1885,  and  which  had  earlier  been  suggested  by  Thomas.'^  The  only 
reason  for  maintaining  the  independence  of  the  affection  was  that  it 
apparently  did  not  protect  from  scarlatina.  The  arguments  advanced 
by  Dukes  did  not  seem  to  me'*  at  all  convincing,  there  being  no  proofs 
given  that  the  disease  was  not  rubella  in  two  epidemics  and  mild  scarlet 
fever  in  the  third.  This  has  been  practically  the  position  maintained  by 
Williams,^  Caiger,^  Pleasants,^  Poynton,^  and  most  of  those  who  have 
given  the  matter  close  attention.  Many  physicians  have  accepted  the 
new  disease,  but  as  yet  no  cases  have  been  reported  which  prove  con- 
vincingly that  the  affection  protects  from  neither  measles  nor  scarlatina, 
and  this  will  be  necessary  before  it  can  properly  be  given  recognition. 
The  question  is  consequently  still  imsettled. 

ERYTHEMA  INFECTIOSUM 

This  disease,  although  previously  described  by  other  observers,  was 
first  claimed  to  be  an  independent  infectious  disorder  by  Escherich^  in 
1896.  Its  position  as  a  distinct  affection  still  remains  to  be  established, 
yet  it  certainly  appears  in  no  way  to  protect  from  scarlatina,  measles  or 
rubella.  An  excellent  review  of  the  subject  is  given  by  Escherich^" 
and  by  Shaw,^^  the  latter  accompanied  b}^  colored  plates.  Epidemics 
have  also  been  described  by  Michalowicz/^  Heisler^^  and  Tobler,^^  The 
disease  has  not-|ret  been  observed  in  English-speaking  countries  as  far 
as  I  am  aware. 

It  occurs  in  epidemics  especially  in  spring  and  summer  (Tobler,  in 
winter)  and  generally  attacks  children  between  4  and  12  years  of  age. 
Adults  also  contract  it,  but  no  case  has  as  yet  been  observed  in  infants 
under  1  year.  It  is  only  feebly  infectious.  The  nature  of  the  germ  is 
unknown. 

1  Lancet,  1900,  XXXIX,  89. 

2  Arch.  f.  Kiriderh.,  1885-6,  VII,  241. 

3  Ziemssen's  Cyclop.  Pract.  Med.  Amer.  Ed.,  1875,  II. 
•>  Phila.  Med.  Journ.,  1902,  April  12. 

6  Brit.  Med.  Journ.,  1901,  II,  1797. 

«  Brit.  Med.  Journ.,  1901,  II,  590. 

^  Phila.  Med.  Journ.,  1902,  May  24,  938. 

8  Brit.  Med.  Journ.,  1901,  II,  594. 

'  Transac.  11th  Internat.  Med.  Cong.,  1896. 

1"  Monatsschr.  f.  Kinderheilk.,  1904,  III,  285. 

11  Amer.  Journ.  Med.  Sci.,  1905,  CXXIX.  16. 

1^  Przegl.  pedj.,  1909,  IV-V.     Ref.  Jahrb.  f.  Kindorh.,  1910.  LXXI,  235. 

13  Mimch.,  nicd.  Woch.,  1914,  LXI,  1684. 

'^  Berl.  khn.  Woch.,  1914,  LI,  514. 


364  THE  DISEASES  OF  CHILDREN 

Symptoms. — The  period  of  mcubation,  as  far  as  yet  determined, 
varies  from  6  to  14  days.  Initial  symptoms  are  generally  absent  or  consist 
only  of  malaise,  discomfort  and  sore  throat.  The  rash  appears  first  on 
the  face  in  the  form  of  a  rose-red  efflorescence  distinctly  raised,  occupying 
especially  the  cheeks,  symmetrical  in  distribution,  disappearing  momen- 
tarily on  pressure,  and  suggesting  erysipelas.  The  skin  is  swollen  and  hot, 
and  the  edges  of  the  affected  area  are  generally  slightly  raised  and  sharply 
defined  in  an  irregular  line.  There  is  no  itching.  The  forehead  and 
chin  exhibit  only  discrete  small  patches  of  bluish-red  color,  and  the  tem- 
ples and  the  oral  circle  are  uninvolved.  On  the  2d  day  the  eruption 
appears  on  the  body,  especially  the  gluteal  region  where  it  is  always  well- 
developed,  and  on  the  outer  surface  of  the  arms  and  legs,  but  only  to  a 
limited  extent  on  the  trunk.  In  these  regions  it  is  less  intensely  colored 
than  on  the  cheeks  and  resembles  rather  the  spots  on  the  forehead.  It  is 
morbilliform  in  character,  but  more  macular  than  papular,  with  some 
confluence  on  the  extensor  surfaces  of  the  arms,  while  on  the  flexor 
surfaces  of  the  arms  and  legs  it  is  always  less  intense.  The  hands  and 
feet  are  the  last  parts  to  be  involved.  In  many  regions  on  the  extremi- 
ties the  rash  has  a  map-like  appearance,  especially  while  fading.  On  the 
trunk  there  are  scattered  discrete  spots,  pea-size  or  larger,  sometimes 
crescentically  grouped ;  or  there  may  be  no  eruption  whatever. 

The  rash  fades  from  the  face  in  4  or  5  days,  and  disappears  entirely 
from  the  body  in  6  to  10  days  from  its  first  appearance.  No  pigmenta- 
tion or  desquamation  follows.  The  mucous  membranes  exhibit  no 
eruption. 

There  are  practically  no  symptoms  attending  the  eruption,  the  lym- 
phatic glands  are  not  swollen,  there  are  no  catarrhal  manifestations,  the 
urine  is  normal,  fever  is  rarely  present,  and  the  child  generally  feels 
perfectly  well. 

In  the  matter  of  diagnosis,  the  disease  is  most  likely  to  be  confounded 
with  rubella,  although  it  is  in  reality  quite  unlike  it.  In  the  latter  disease 
the  rash  spreads  uniformly  over  the  body  and  is  well  developed  in  the 
oral  circle  and  on  the  forehead  and  exhibits  either  discrete  small  macules 
or  a  widespread  confluence  over  the  cutaneous  surface.  The  lymphatic 
glands  are  enlarged.  None  of  this  is  true  of  infectious  erythema.  Measles 
may  resemble  it  closely,  yet  superficially,  in  the  appeaiance  of  the  erup- 
tion on  the  extremities.  The  involvement  of  the  mucous  membrane  in 
this  disease,  the  presence  of  buccal  or  palatal  eruption,  the  distribution  of 
the  rash,  and  the  fever  and  catarrhal  symptoms  serve  to  distinguish  it. 
Scarlet  fever  has  but  slight  resemblance.  The  general  symptoms,  the 
appearance  of  the  throat  and  the  distribution  of  the  rash  are  characteristic 
in  this  disease.  The  medicamentous  and  other  erythemata  have  little 
in  common  with  infectious  erythema,  and  the  history,  course  and  dis- 
tribution of  their  eruptions  aid  in  distinguishing  them. 

The  prognosis  is  entirely  favorable,  there  are  no  complications  and 
sequels,  and  treatment  is  not  required. 


VARIOLA  365 

CHAPTER  VI 
VARIOLA 

(Small-pox) 

Small-pox  is  now  seen  but  seldom  in  children  where  the  practice  of 
vaccination  is  prevalent,  yet  some  description  of  it  is  requisite  on  account 
of  the  danger  of  confounding  its  modified  form  (varioloid)  with  varicella. 

It  has  existed  since  earliest  times  in  Asia  and  since  at  least  the  7th 
century  in  Europe.  The  best  early  description  of  it  was  by  Rhazes  in 
the  first  part  of  the  10th  century.^  It  appeared  in  America  in  the  16th 
century. 

Etiology.  Predisposing  Causes. — Race,  climate  and  locality  exert 
no  influence,  the  disease  being  spread  over  all  parts  of  the  earth.  Sex 
and  age,  too,  do  not  affect  its  occurrence.  The  infant  may  be  born 
suffering  from  the  disease,  or  having  already  passed  through  an  attack, 
or  it  may  develop  it  soon  after  birth  as  easily  as  at  any  later  period  of 
life.  The  individual  susceptibihty  is  very  great,  and  the  majority  of 
unprotected  persons  exposed  contract  the  disorder.  Yet  an  immunity; 
temporary  or  permanent,  is  found  occasionally  to  exist.  The  affection 
is  particularly  prone  to  appear  in  large  epidemics,  which,  at  least  in  tem- 
perate climates,  reach  their  maximum  during  the  cold  months  of  the 
year. 

Exciting  Cause. — The  disease  is  one  of  the  most  contagious  known, 
yet  the  nature  of  the  germ  has  never  been  positively  determined.  It 
seems  possible  that  it  is  a  protozoan  (the  cytoryctes  variolse),  described 
by  Guarnieri,2  Councilman,  Magrath,  and  Brinkerhoff,^  and  others; 
but  it  is  claimed  by  Proescher*  and  others  that  these  bodies  are  only 
proteid  end-products. 

Transmission, — The  transmission  of  the  germ  by  inoculation  was 
long  made  use  of  in  "variolation."  It  is  transmitted  also  by  direct 
contact,  and,  as  generally  believed,  to  an  unusual  degree  through  the 
surrounding  air,  from  a  distance  of  several  hundred  yards.  This  is, 
however,  denied  by  many.  It  is  readily  carried  by  clothing,  insects  and 
the  like,  or  by  a  third,  healthy  person.  The  infection  certainly  resides 
in  the  pustules  and  the  crusts.  It  does  not  appear  to  be  contained  in  the 
mucous  secretions  unless  contaminated  by  pustular  discharge.  The 
blood,  however,  has  been  proven  to  be  infectious  and  it  is  also  evident 
that  the  disease  can  in  some  way  readily  be  communicated  before 
the  eruption  appears.  Danger  of  infection  by  the  patient  ceases  by  the 
time  the  crusts  have  fallen  and  the  skin  has  become  smooth.  The 
tenacity  of  life  of  the  germ  is  very  great  and  may  continue  even  for  some 
years.  The  poison  is  generally  received  by  way  of  the  respiratory 
tract  and  sometimes  by  the  digestive. 

Pathological  Anatomy. — The  earliest  step  in  the  formation  of 
the  pock  is  a  circumscribed  hyperemia  followed  by  a  necrosis  of  the  epi- 
dermal cells,  beginning  in  the  Malpighian  layer.  The  cells  now  fuse  into 
a  reticular  framework,  as  seen  later  in  the  vesicle,  and  transudation  of 

^  De  variolis  et  morbillis,  Lend.,  1756. 

2  CentraU)!.  f.  Bakt.,  1894,  XVI,  299. 

=»  Journ.  Med.  Rescarcli,  19(«,  IX,  372;  1904,  XI,  12. 

*  New  York  Med.  Journ.,  1913,  XCVII,  741. 


366 


THE  DISEASES  OF  CHILDREN 


serum  takes  place  into  the  lesion,  with  a  proliferation  of  cells  in  the  peri- 
phery. The  combination  of  these  changes  forms  the  papule.  Continued 
transudation  of  fluid  produces  the  vesicle.  Most  investigators  believe 
that  umbiHcation  results  from  the  holding  down  of  the  central  portion 'of 
the  surface  of  the  vesicle  by  the  reticular  bands  beneath  it,  while  the 
cellular  proliferation  of  the  periphery  raises  this  portion  higher.  The 
increasing  tension  later  tears  away  the  reticulum  and  the  umbilication 

disappears.  Effusion  of  blood  may 
take  place  into  the  lesion.  Leuco- 
cytes in  constantly  increasing  num- 
ber enter  the  vesicle  and  a  pustule 
results.  They  may  penetrate  too, 
the  tissues  forming  its  base,  until 
the  whole  thickness  of  the  skin  is 
involved.  If  this  occurs,  scarring 
results. 

Analogous  changes  take  place  in 
the  mucous  membrane  of  the 
mouth,  throat,  eyes,  nose,  larynx, 
trachea,  bronchi,  esophagus,  rectum, 
vagina,  ureter,  and  urethra.  Some- 
times a  pseudo-membrane  covers 
the  ulcers  produced.  Petechiae 
may  be  present  on  the  mucous 
membrane  as  well  as  on  the  skin. 

Hemorrhage  may  be  discovered 
in    the    serous     membranes,     the 
various  organs,   the  muscles,  and 
the    medullary    cavities      of    the 
bones.     This  is  especially  true  of 
the  hemorrhagic  type  of  the  disease. 
Hypostatic   pulmonary  congestion 
and  bronchopneumonia  are  common 
post-mortem    lesions.      In     cases 
which  have  passed  into   the  sup- 
purative   stage,     parenchymatous 
degeneration  of  the  liver,  heart  and 
kidneys  is  found,  and  the  spleen 
and  lymphatic  glands  are  enlarged. 
Symptoms. — The     symptoms 
vary  to  such   a   degree   with   the 
type  of  the  disease,  that  it  is  more 
convenient    first  to    describe    the 
ordinary  form  (Variola  vera)  and  then  the  modifications  which  may  arise. 
(A)  Variola  Vera.     Discrete  Small-pox  (Fig.  76). — In  this,  the 
usual  form  of  small-pox,  the  lesions  are  discrete  throughout,  or  confluent 
on  the  face  and  hands  only. 

Period  of  Incubation. — This  is  usually  12  to  14  days,  although  it  may 
vary  from  5  up  to  20  or  more.  As  a  rule  no  sj^mptoms  are  present,  but 
occasionally  the  last  days  of  this  period  are  marked  by  malaise,  dullness, 
headache,  and  loss  of  appetite. 

Period  of  Invasion. — The  onset  is  generally  sudden,  with  repeated 
vomiting,  prostration,  headache,  pain  in  the  back,  Iknbs,  and  epigastrium, 
loss  of  appetite,  coated  tongue,  thirst,  high  fever  and  rapid  pulse.     Con- 


FiG.  76. — Discrete  S.\iali.-pi/x. 
Occurring  in  an  unvaccinated  girl.     8th 
day  of    eruption.     (Welch   and  Schamberg, 
Acute  Contagious  Diseases,    1905,    PL    XV, 
opp.  p.  179.) 


VARIOLA  367 

vulsions  often  usher  in  the  attack  in  early  life.  A  chill  may  occur  in 
older  children.  Diarrhea  may  replace  the  constipation  present  in  adults. 
The  temperature  rises  very  rapidly  to  103°  or  104°F.  (39.4°  or  40°C.) 
or  more.  There  is  restlessness,  either  sleeplessness  or  drowsiness,  and  often 
delirium. 

On  the  2d  day  the  pain  in  the  back  and  head  and  the  rapid  pulse 
persist,  and  occasionally  the  convulsions,  vomiting  and  abdominal  pains 
also;  and  the  temperature  continues  unaltered  or  even  rises.  Not 
infrequently,  but  less  often  in  children,  a  prodromal  rash  is  observed, 
which  is  scarlatiniform  or  morbilliform  in  type.  The  scarlatiniform  rash 
is  generally  limited  to  the  inner  surface  of  the  thighs,  the  lower  part  of 
the  abdomen,  the  axillae,  and  the  sides  of  the  chest;  but  sometimes  covers 
the  entire  surface  and  in  color  suggests  erysipelas.  The  morbilliform 
eruption  is  irregularly  distributed,  either  in  limited  areas  or  more  widely 
spread.  The  prodromal  rash  may  disappear  before  the  characteristic 
eruption  of  the  disease  develops,  or  may  last  for  a  time  after  its  appear- 
ance. Petechise  are  sometimes  seen  in  cases  destined  to  be  hemorrhagic. 
The  duration  of  the  period  of  invasion  is  from  2  to  3  days.  The  general 
symptoms  of  the  2d  day  continue  unabated  until  the  eruption  begins  to 
develop. 

Period  of  Eruption.  The  Rash.- — On  the  3d  or  sometimes  the  4th  day 
from  the  onset  of  the  initial  symptoms  the  characteristic  eruption  begins 
to  show  itself.  The  individual  lesion  consists  at  first  of  a  red  macule 
which  gradually  becomes  more  prominent  and  is  transformed  into  a 
hard,  elevated  papule  by  the  2d  day  (the  4th  of  the  disease).  It  now 
gives  the  often-described  sensation  as  of  a  shot  beneath  the  skin.  On 
the  3d  day  of  the  eruption  (the  5th  of  the  disease),  a  minute  vesicle 
appears  in  the  centre  and  grows  slowly  to  the  5th  or  6th  day,  when  it 
is  as  large  as  a  good-sized  split  pea,  very  firm,  of  a  mother-of-pearl  color, 
circular,  slightly  flattened  on  top,  often  with  a  central  umbilication,  and 
with  a  narrow  red  areola.  Pricking  with  a  needle  allows  a  small  quantity 
of  serum  to  exude,  but  the  vesicle  does  not  collapse;  that  is  to  say,  it  is 
multilocular. 

By  the  6th  day  of  the  eruption  (the  8th  of  the  disease)  suppura- 
tion begins  and  proceeds  rapidly,  and  by  the  8th  or  9th  day  is  at  its 
height,  the  vesicle  having  become  a  yellow,  entirely  opaque  pustule,  of 
globular  form  without  umbilication,  and  surrounded  by  a  very  distinct 
areola  with  much  swollen  skin  about  it.  The  pustule  may  rupture  in  a 
day  or  more  or  may  remain  unruptured,  while  a  secondary  umbilication 
develops. 

The  regions  first  attacked  are  generally  the  face  and  wrists  whence 
the  rasTi  extends  to  the  head,  hands,  and  arms,  and  in  24  hours  to  the 
trunk  and  then  to  the  lower  extremities,  occupying  about  3  days  before 
it  reaches  its  fullest  extent.  By  this  time  the  entire  surface,  but  especially 
the  face  and  head,  is  well  covered,  the  rash  having  become  vesicular  in 
the  region  first  attacked,  while  still  macular  or  papular  elsewhere.  The 
parts  of  the  body  constantly  exposed  to  the  air  show  the  greatest  number 
of  lesions,  the  trunk  being  nearly  always  least  involved.  In  adults  the 
distal  portions  of  the  limbs  are  more  affected  than  the  proximal,  but  this 
is  less  well-marked  in  children.  The  lesions  are  separated  from  each 
other  by  skin  that  is  normal  except  for  the  swelling,  which  is  especially 
marked  on  the  face,  hands  and  feet.  In  some  cases  the  pocks  appear 
everywhere  simultaneously;  in  others  first  on  some  other  regions  than  the 
usual  ones.     They  may  number  some  hundreds  in  an   average  case. 


368 


THE  DISEASES  OF  CHILDREN 


Those  upon  the  palms  and  soles  consist  at  first  of  macules  surrounded 
by  an  indurated  area.  They  become  flattened,  deep-seated  vesicles,  but 
do  not  pass  through  a  papular  stage. 

Simultaneously  with  the  cutaneous  eruption,  or  a  little  earher,  le- 
sions may  be  found  on  the  mucous  membrane  of  the  mouth,  pharynx, 
nose,  and  sometimes  the  larynx,  vagina,  rectum  and  eyes.  These  run 
a  course  similar  to  those  upon  the  skin,  except  that  the  vesicles  soon 
rupture  and  leave  ulcerated  surfaces. 

Symptoms  Attending  the  Erup- 
tion.— With  the  appearance  of  the 
rash  upon  the  skin,  or  shortly  after 
or  before  it,  there  is  usually  a  sud- 
den or  gradual  fall  of  temperature 
to  normal  or  nearly  so,  and  the 
constitutional  symptoms  improve 
greatly  (Figs.  77  and  80).  When 
suppuration  begins  on  the  6th  day 
of  the  rash,  the  temperature  grad- 
ually rises  again  with  morning 
remissions.  This  is  called  the 
"secondary"  or  "suppurative" 
fever.  Then  follows  increase  of 
temperature  until  about  the  11th 
or  12th  day  of  the  eruption  when 
it  falls  by  lysis  in  favorable  cases, 
the  elevation  reached  being  gener- 
ally less  than  in  the  stage  of  in- 
vasion. With  the  onset  of  the 
secondary  fever  the  pulse  and 
respiration  again  become  rapid, 
the  heart  often  weak,  and  pros- 
tration decided.  There  is  severe 
pain,  swelling,  tension,  and  itching 
of  the  face,  neck  and  extremities. 
The  eyes  may  be  closed  and  nasal 
respiration  obstructed;  the  face  so 
swollen  that  the  patient  is  unrecog- 
nizable. Restlessness,  sleepless- 
ness, and  delirium  are  common. 
The  throat  is  sore  and  swallowing 
difficult,  thirst  excessive,  the  tongue 
parched,  the  breath  foul,  the  teeth 
and  gums  covered  with  sordes, 
diarrhea  may  occur,  and  conjunctivitis  and  cough  are  common.  The 
urine  often  contains  albumin  and  casts.  The  discharging  pus  from 
ruptured  lesions  produces  a  very  offensive  odor.  The  pain  which  the 
swelling  of  the  skin  occasions  at  this  period  is  often  intense  and  every 
movement  or  even  the  pressure  of  the  bed  or  the  bed-clothes  may  be 
the  cause  of  great  suffering. 

The  blood  in  small-pox  exhibits  a  diminution  of  hemoglobin  early 
in  the  disease.  The  red  blood-corpuscles  tend  to  form  irregular  clumps 
instead  of  rouleaux.     Magrath,  Brinkerhoff  &  Bancroft^  confirm  the 


Fig  77. — Discrete  Small-pox  with  Typical 
Course. 
Emily  E.,  aged  5  years.  Never  vac- 
cinated. Mar.  2,  nausea,  headache,  aching 
in  legs  and  back,  fever;  Mar.  5,  amelioration 
in  symptoms,  papular  rash  developing  on 
face;  Mar.  7,  decided  fall  of  temperature, 
vesicles  appearing;  Mar.  10,  rise  of  tempera- 
ture with  pustular  stage.  From  a  patient 
in  the  Philadelphia  Hospital  for  Contagious 
Diseases.     Courtesy  of  Dr.  B.  Franklin  Royer. 


1  Journ.  Med.  Research,  1904,  XI,  247. 


VARIOLA 


369 


observations  of  previous  investigators,  that  a  varying  degree  of  leucocy- 
tosis,  especially  of  the  mononuclear  cells,  is  present  during  the  eruptive 
stage. 

Period  of  Desquamation. — Drying  begins  about  the  11th  or  12th 
day  of  the  eruption,  generally  first  in  the  lesions  which  were  first  to  appear. 
By  the  14th  or  loth  day,  in  average  cases,  this  process  is  well  under  waj^, 
and  the  crusts  begin  to  fall.  Many,  however,  are  very  adherent  and  do 
not  separate  until  during  the  4th  week  or  later,  unless  removed  forcibly. 
Following  the  separation  a  branny  desquamation  occurs.     On  the  hands 


^ 


s 


i£. 


SfEl 


Adult 
vomiting, 


Fig.  78. — -Coxfluext  S.mall-pox. 
Never  vaccinated.    June  25,  very  intense  headache  and  backache,  with  dizziness, 
chills, 


vuiiiiiiiis.  i-'""^.  ^nd  high  fever;  June  28,  been  very  ill  and  in  great  pain,  widespread 
papular  eruption  appeared  this  date  and  spread  rapidly;  July  1,  vesiculation  began,  lasted 
3  days,  became  confluent  on  face,  legs,  wrists,  and  forearms;  July  4,  pustulation  began, 
great  pain  and  high  fever  which  lasted  until  death.  From  a  patient  in  the  Philadelphia 
Hospital  for  Contagious  Diseases.     Courtesy  of  Dr.  B.  Franklin  Royer. 


and  feet  the  entire  skin  may  be  shed  in  the  form  of  moulds.  After  des- 
quamation is  over  there  remains  a  reddish  pigmentation,  later  becoming 
brownish.     The  normal  color  is  regained  only  after  weeks  or  months. 

With  the  beginning  of  desiccation  th(^  swelling  and  pain  in  the  skin 
lessen,  the  areola)  about  the  pustules  grow  smaller,  the  temperature 
begins  to  fall  and  the  symptoms  in  general  improve.  The  itching  of  the 
skin  is  now  frequently  intense.  The  hair  often  falls  out  temporarily. 
Feebleness  of  body  and  of  min<l  may  persist  for  several  weeks  and  disap- 
pear only  slowly.  Any  scarring  left  by  the  disease  does  not  assume  the 
characteristic  white;  appearance  for  3  or  4  montiis. 

The  principal  well-defined  modifications  of  the  type  of  the  disease 
are  {B)  Confluent  small-pox,  (C)  Hcmorrhaijic  small-pox,  (D)  Mild 
small-pox,  (E)  Varioloid,  or  small-pox  inodijied  by  vaccination. 

24 


370  THE  DISEASES  OF  CHILDREN 

(E)  Confluent  Small-pox. — This  form  is  characterized  by  the 
tendency  of  the  lesions  to  fuse,  generally  with  an  increase  in  severity 
of  all  the  constitutional  symptoms.  The  prodromes  are  the  ordinary 
ones,  but  always  severe.  The  eruption  appears  at  the  usual  time  or 
often  somewhat  earlier,  and  spreads  with  great  rapidity.  The  lesions 
are  closely  crowded,  and  the  swelling  and  redness  of  the  skin  come  on 
early.  Sometimes  the  face  assumes  a  general  redness  at  the  beginning 
of  the  eruptive  period  instead  of  exhibiting  the  ordinary  macules.  In 
the  suppurative  stage  many  of  the  pustules  fuse  into  irregularly  shaped 
suppurating  areas,  especially  on  the  face  and  extremities,  but  on  the  trunk 
they  continue  discrete.  The  entire  face  may  be  covered  by  one  enor- 
mous pustule.     The  involvement  of  the  throat  is  usually  extensive. 

The  subsidence  of  symptoms  and  the  fall  of  temperature  seen  as  the 
eruption  is  developing  are  less  than  in  discrete  small-pox.  Then,  with 
the  onset  of  suppuration  or  before  it,  all  the  general  symptoms  are  mani- 
fested in  great  force.  Vomiting  and  retching  may  be  continuous,  the 
cervical  lymphatic  glands  are  much  enlarged  and  the  temperature  is  high 
with  little  remission  (Fig.  78).  The  symptoms  in  general  are  those  of 
intense  toxemia.     The  crusts  which  form  later  are  slow  in  being  shed. 

(C)  Hemorrhagic  Small-pox. — This  is  the  malignant  form  of  the 
disease.  The  incubation  is  often  very  short.  The  hemorrhagic  tend- 
ency may  develop  either  in  the  prodromal  or  in  the  eruptive  stage.  In 
the  former,  called  purpura  variolosa  or  ''black  small-pox,"  the  symptoms 
are  violent  and  a  purpuric  rash  appears,  at  first  petechial  and  later  ec- 
chymotic.  Much  of  the  surface  of  the  body  may  exhibit  an  almost 
uniform  purplish  color.  Hemorrhage  from  various  mucous  membranes 
may  occur,  of tenest  from  the  renal.  Generally  the  true  eruption  of  small- 
pox does  not  develop ;  or,  if  the  patient  live  until  the  time  of  the  eruptive 
period,  is  represented  by  a  few  papules  only.  There  may  be  delirium 
or  stupor,  but  often  the  mind  remains  clear  throughout.  This  is  the 
most  malignant  form  of  the  disease. 

In  the  second  variety  of  hemorrhagic  small-pox,  called  variola  pus- 
tulosa  hemorrhagica,  the  earlier  stages  of  the  disease  are  severe,  but  there 
is  nothing  characteristic  until  the  vesicles  or  pustules  begin  to  form. 
The  hemorrhagic  tendency  then  develops  either  slowly  or  rapidly.  Bleed- 
ing takes  place  into  the  lesions  and,  in  the  still  severer  cases,  into  the  sur- 
rounding tissues  and  from  the  mucous  membranes.  The  mind  usually 
remains  clear. 

{D)  Mild  Small-pox. — Individual  cases,  or  even  epidemics,  occur 
in  which,  although  there  has  been  no  protection  by  vaccination,  the  course 
of  the  disease  is  extremely  mild.  The  lesions  are  few  in  number  or  en- 
tirely absent  (Variola  sine  eruptione),  and  the  constitutional  symptoms 
mild  or  insignificant.  Occasionally  the  prodromes  are  of  the  usual  sever- 
ity, but  the  development  of  the  eruption  is  abortive,  and  the  whole  course 
of  the  disease  greatly  curtailed,  the  condition  being  entirely  similar  to 
varioloid. 

(E)  Varioloid;  Modified  Small-pox. — This  is  the  form  observed 
in  persons  partially  protected  by  vaccination.  It  is  characterized  by 
its  mildness  and  the  comparatively  small  number  and  rudimentary 
nature  of  the  lesions.  The  disease,  however,  does  not  differ  in  nature 
from  ordinary  small-pox  and  is  as  capable  of  producing  the  unmodified 
form  in  unprotected  persons.  The  stage  of  invasion  is  more  variable 
than  in  discrete  small-pox,  ranging  often  from  1  or  2  days  up  to  4  or  5 
days.     The  prodromal  symptoms  may  be  the  ordinary  ones  of  small- 


VARIOLA 


371 


pox  or  may  be  mild  and  even  overlooked.  A  prodromal  rash  is  frequent, 
especially  of  the  rubeoloid  form.  The  distribution  of  the  lesions  is  very- 
variable.  Sometimes  only  about  half  a  dozen  may  be  found,  or  even 
exceptionally  none  at  all.  They  are  often  confined  to  the  face  and  hands. 
In  other  cases  they  may  be  quite  numerous  or  may  even  be  confluent  or 
partially  so.  As  a  rule  they  develop  first  on  the  face  and  spread  rapidly. 
Their  first  appearance  is  that  of  red  macules,  suggesting  the  roseola 
of  typhoid  fever.  These  quickly  change  into  papules  and  then  some  of 
them  into  vesicles,  while  others  never  pass  the  papular  stage.  Many  of 
the  vesicles  do  not  suppurate  but  rapidly  dry  into  crusts;  others  become 
purulent,   but  are  superficial,  soon  dry,  and  rarely  leave  scars.     The 


Fig.  79. — Varioloid. 
Adult.  Vaccinated  in  youth.  Nov.  1,  headache  and  backache,  high  fever,  nausea, 
dizziness;  Nov.  3  symptoms  continued  until  this  date,  when  generalized  papular  eruption 
developed;  Nov.  4,  vesicles  developed,  but  nearly  all  dried  in  this  stage,  a  few  pustules 
without  secondary  fever.  From  a  patient  in  the  Philadelphia  Hospital  for  Contagious 
Diseases.     Courtesy  of  Dr.  B.  Franklin  Royer. 


entire  crop  of  lesions  also  develops  more  rapidly  than  in  unmodified 
small-pox  and  is  present  within  12  hours  from  the  first  evidence  of 
eruption.  There  are  no  large  areolae  and  no  severe  swelling  of  the  skin. 
With  the  first  appearance  of  the  eruption  the  initial  fever  falls  rai)idly 
by  crisis  and  is  seldom  again  elevated,  the  suppurative  fever  being  absent 
and  all  symptoms  disappeai'ing.  The  whole  process  is  much  shorter 
than  in  variola  vera  and  the  desiccation  begins  earlier  and  is  soon  com- 
pleted (Fig.  79). 

Complications  and  Sequels. — Affections  of  the  respiratory 
apparatus  are  among  the  most  frequent  complications  of  variola.  Laryn- 
gitis is  common,  and  in  severe  attacks  involvement  of  the  cartilages  may 
occur,  or  edema  of  the  glottis  cause  death.     Bronchitis  is  invariable  in 


372 


THE  DISEASES  OF  CHILDREN 


severe  attacks  of  small-pox  and  bronchopneumonia  is  almost  always 
present  in  fatal  cases.  Lobar  pneumonia  is  uncommon,  but  pleurisy, 
especially  of  the  purulent  form,  is  frequent.  A  pseudodiphtheritic 
inflammation  of  the  throat  is  not  uncommon.  Cardiac  complications 
are  rare,  myocarditis,  occurring  oftener  than  other  forms.  Otitis  is 
observed  occasionally  and  conjunctivitis,  keratitis,  and  iritis  not  infre- 
quently, sometimes  followed  by  more  or  less  permanent  impairment  of 
sight.  Albuminuria  is  common,  but  nephritis  is  rare.  Multiple  cuta- 
neous abscesses  are  of  frequent  occurrence  as  sequels  (Fig.  80).  Bed 
sores  or  gangrene  may  develop,  and  suppurative  adenitis  is  not  infrequent. 


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Fig.  so. — Discrete  Small-pox  Fcllowed  by  Boils  and  Abscesses,  Prolonging  the 

Temperature. 
Adult.     Usual  prodromes  began  Nov.  27  and  patient  was  severely  ill  for  3  days;  papu- 
lar eruption  on    Nov.  30,    with   rapid   subsidence   of   all   symptoms;  boils    and    abscesses 
appeared  on  Dec.  16.     From  a  patient  in  the  Philadelphia  Hospital  for  Contagious  Dis- 
eases.     Courtesy  of  Dr.  B.  Franklin  Royer. 

Among  nervous  disorders  neuritis  is  an  occasional  sequel  and  myelitis, 
encephalitis  and  meningitis  may  occur  as  complications. 

Small-pox  may  coexist  with,  follow  or  precede  other  acute  infec- 
tious diseases  but  this  appears  to  be  very  exceptional.  Erysipelas  may 
develop  as  a  sequel  during  convalescence. 

Relapse  and  Recurrence. — Relapse;  i.e.  a  second  attack  developing 
before  the  poison  is  out  of  the  system  is  rarely  observed.  Recurrence 
of  small-pox  is  sometimes  seen,  but  is  very  uncommon.  As  a  rule  one 
attack  confers  a  life-long  immunity,  and  a  second  occurrence  is  usually 
mild.  Vaccination  gives  an  immunity  which  may  be  permanent  or 
only  temporary.     (See  Vaccination,  p.  380.) 

Prognosis. — The  mortahty  of  unmodified  small-pox  is  high,  varying 
from  25  to  45  per  cent,  or  more.  The  character  of  the  epidemic  is  one  of 
the  important  factors.     In  some  outbreaks  the  virulence  is  but  slight, 


VARIOLA  373 

and  few  cases  die.  Various  causes  influence  it.  In  infancy  and  early 
childhood  the  number  of  deaths  is  very  large.  Statistics  of  the  Hospital 
for  Contagious  Diseases  of  Philadelphia  (Welch  and  Schamberg)  ^  gave  a 
mortality  of  61.66  per  cent,  in  subjects  under  1  year,  as  compared  with  a 
total  mortality  of  31.79  per  cent.  A  mild  initial  stage  generally  presages 
a  mild  attack.  Severe  initial  symptoms,  however,  do  not  necessarily 
indicate  that  the  attack  as  a  whole  will  be  severe.  Death  may  occur  in 
any  stage  of  the  disease.  In  many  cases  the  initial  symptoms  are  so 
grave  that  children  die  before  the  eruptive  stage  develops.  Danger 
again  arises  during  the  suppurative  period,  and  it  is  at  this  time,  about 
the  11th  or  12th  day  of  the  disease,  that  the  majority  of  deaths  take 
place.  A  widespread,  intense,  scarlatiniform  prodromal  eruption  is  an 
unfavorable  symptom,  often  indicating  the  onset  of  hemorrhagic  small- 
pox. The  morbilliform  prodromal  rash  is  rather  a  good  omen.  The 
presence  of  petechias  during  invasion  is  generally,  but  not  necessarily,  an 
unfavorable  indication.  A  fall  of  temperature  occurring  promptly  with 
the  development  of  the  rash  promises  a  mild  attack,  while  unusually  high 
fever  during  the  period  of  eruption  is  unfavorable  and  may  signify  that  a 
fatal  ending  is  immediately  impending.  The  sooner  the  suppurative 
fever  begins  to  fall  the  better  the  prognosis  and  the  less  danger  there  is 
of  threatening  complications  developing.  Severe  nervous  symptoms 
during  the  eruptive  period  are  an  unfavorable  indication,  as  is  an  abund- 
ant eruption  on  the  mucous  membrane  of  the  mouth  and  throat.  The 
danger  of  the  disease  is  usually  in  direct  proportion  to  the  number  of 
pocks  and  the  amount  of  suppuration.  Confluent  small-pox  gives  a 
very  high  mortality,  especially  under  5  years  of  age.  The  great  majorit}^ 
of  hemorrhagic  cases  die.  The  prognosis  in  modified  small-pox  is  nearly 
always  good,  depending  upon  the  degree  of  j)rotection  which  vaccination 
has  afforded. 

Diagnosis. — In  well-developed  small-pox  the  diagnosis  can  scarcely 
fail  to  be  made.  Early  in  the  disease,  however,  or  later  in  very  mild 
cases,  and  especially  in  the  modified  form,  it  may  be  very  difficult.  The 
characteristic  diagnostic  symptoms  are  the  severe  pain  in  the  head  and 
back  in  the  initial  stage,  the  sudden  drop  of  temperature  about  the  begin- 
ning of  the  eruptive  period,  and  the  well-marked  papular  stage  through 
which  the  eruption  passes.  Early  in  its  development  the  rash  has  often 
been  mistaken  for  typhoid  fever.  At  this  period,  too,  it  may  strongly 
resemble  measles,  and  errors  in  diagnosis  have  frequently  been  made. 
The  absence  of  the  catarrhal  symptoms  of  measles,  however,  and  of  the 
Koplik  spots  aid  in  excluding  this.  The  morbilliform  prodromal  eruption 
of  small-pox  may  likewise  suggest  measles.  This  eruption,  however, 
is  not  at  all  elevated  as  is  the  rash  of  measles.  The  scarlatiniform  pro- 
dromal rash  may  lead  to  the  suspicion  of  scarlet  fever.  The  absence  of 
initial  sore  throat,  and  the  localization  of  the  eruption  elsewhere  than  first 
on  the  face  and  chest,  serve  to  exclude  the  latter  disease.  Further,  the 
prodromal  rashes  are  not  common  in  children.  I  have  seen  a  generalized 
vaccinal  eruption  occasion  confusion.  The  development  of  the  rasli  at 
the  same  time  with  the  vaccine  vesicle  and  the  absence  of  all  the  character- 
istic initial  symptoms  of  small-pox  render  the  diagnosis  generally  easy, 
yet  not  always  so,  as  the  vaccination-pocks  of  vaccinia  may  occur  in  combi- 
nation with  that  of  small-pox  (Fig.  81).  The  pustular  syphiloderm  also 
may  be  mistaken  for  small-pox.     The  slower  onset  and  course,  the  ap- 

^  Acute  Contagious  Diseases,  1905,  275. 


374 


THE  DISEASES  OF  CHILDREN 


pearance  of  the  eruption  in  successive  crops,  the  history,  and  the  presence 
of- other  evidences  of  syphihs  aid  in  recognizing  this  affection.  Varicella 
occurring  in  a  severe  form  is  the  disease  causing  the  greatest  diagnostic 
difficult3^  This  is  especially  true  in  the  exceptional  cases  where  the 
stage  of  invasion  of  varicella  has  been  unusually  long  or  well-marked. 
So,  too,  mild  varioloid  may  closely  simulate  ordinary  varicella.  In 
varicella,  however  there  is  a  rapid  development  and  drying  of  the  vesicles, 
and  in  small-pox,  even  in  the  modified  form,  the  invariable  presence  of  a 
papular  stage  and  a  slower  desiccation.  In  varicella,  again,  is  the  occur- 
rence, side  by  side,  of  lesions  in  all  stages  of  development,  and  in  variola 
the  existence  of  but  a  single  crop  in  any  one  locality.     The  rash  of  vari- 


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Fig.  81. — Modified  Small- pox  and  Vaccination  Occurring  Together. 
Philip  C.,  aged  7  months.  Exposed  to  small-pox  from  Oct  24  to  Nov.  1.  Vaccinated 
Nov.  1;  began  to  take  actively  by  Nov.  4;  eruption  of  small-pox  appeared  Nov.  7,  but 
dried  in  vesicular  stage.  Fever  probably  due  in  part  to  active  vaccination.  From  a 
patient  in  the  Philadelphia  Hospital  for  Contagious  Diseases.  Courtesy  of  Dr.  B.  Franklin 
Royer. 


cella  is  most  abundant  on  the  trunk,  especially  in  the  back;  that  of  variola 
on  the  face  and  the  distal  parts  of  the  extremities.  These  differences 
make  the  diagnosis  generally  clear.  Yet  in  spite  of  them  mistakes  are 
frequent  and  easily  made. 

Treatment.  Prophylaxis.  Quarantine. — Owing  to  the  intense 
infectiousness  of  the  disease,  any  suspected  case  should  be  isolated 
absolutely  at  once.  The  extreme  diffusibility  of  the  poison  renders 
quarantine  in  private  houses  very  difficult,  and  treatment  in  special 
hospitals  is  to  be  highly  recommended.  When  this  is  impossible  the 
patient  should  be  confined  to  his  room  in  the  method  recommended  for 
infectious  diseases  in  general  (p.  307),  and  all  non-immune  persons  should 
leave  the  house.     These  must  necessarily  be  kept  under  surveillance  and 


VARIOLA  375 

away  from  other  persons  until  a  time  equalling  that  of  the  period  of 
incubation  is  past.  Everyone  exposed  should  be  promptly  vaccinated, 
since  by  its  more  rapid  development  vaccination  may  modify  or  even 
prevent  the  action  of  the  small-pox  infection  (Fig.  81).  The  isolation  of 
the  patient  must  continue  until  every  vestige  of  the  disease  has  disap- 
peared. This  takes  longest  on  the  thick  epidermis  of  the  palms  and  soles. 
The  time  is  necessarilj^  very  variable  but  averages  4  to  G  weeks  from  the 
onset  of  the  disease.  The  patient,  the  room,  and  every  article  which  has 
been  exposed  should  then  receive  the  most  thorough  disinfection.  The 
patient  should  be  given  a  bath  of  1  :  10,000  corrosive  sublimate  solution 
and  the  room  be  thoroughly  fumigated  with  formalin.  Attention  to 
detail  cannot  be  too  minute. 

Treatment  of  the  Attack. — This  is  necessarily  purely  symptomatic. 
The  patient  should  be  kept  scrupulously  clean.  The  bed-clothing  should 
be  light  and  changed  often,  the  room  well  ventilated  and  moderately  cool, 
the  food  light  but  nourishing  and  administered  frequently.  Water  should 
be  given  freely.  The  aching  of  the  initial  stage  may  require  opiates,  and 
the  fever  may  need  to  be  controlled  by  suitable  hydrotherapy.  The  free 
use  of  cardiac  stimulants  is  indicated  if  there  is  any  evidence  of  weakness. 
Such  sedatives  as  the  bromides  and  chloral  msiy  be  required,  if  great 
nervous  excitement  exists. 

Many  methods  have  been  recommended  for  the  treatment  of  the  cuta- 
neous eruption.  None  possesses  undoubted  power  to  check  the  tendency 
to  pitting,  although  the  cutting  off  of  the  sun's  chemical  rays  by  the 
exposure  to  red  light  only  has  had  much  said  in  its  favor.  Welch  and 
Schambei'g^  believe  some  good  has  been  accomphshed  by  the  employment 
of  tincture  of  iodine.  It  may  be  diluted  if  necessar^^  Much  can  be  done 
to  alleviate  the  tension  and  itching  of  the  skin  by  the  application  of 
cold,  wet  dressings  changed  frequently,  or  of  glycerin  and  water,  or  oily 
substances.  The  employment  of  a  mask  to  keep  these  in  place  is  often 
serviceable.  Except  for  young  children  the  oily  dressings  may  contain 
carbolic  acid.  Ichthyol  (5  to  10  per  cent.)  has  been  highly  recommended 
for  local  use.  It  is  important  to  keep  the  crusts  always  moist  with  aque- 
ous or  oily  substances,  and  frequent  warm  bathing  is  useful  in  favoring 
their  softening  and  removal  as  well  as  earlier  for  the  relief  of  the  cuta- 
neous irritation. 

The  local  conditions  of  the  mouth,  throat  and  nose  require  astringent 
and  cleansing  gargles,  washes  and  sprays.  The  holding  of  ice  in 
the  mouth  or  the  employment  of  orthoform  or  cocaine  locally  often 
gives  great  relief.  The  eyes  must  be  cleansed  several  times  a  day  with 
boric  acid  or  other  mild  antiseptic  solutions.  During  the  suppurative 
stage  the  importance  of  abundant  nourishment  is  very  great  and  free 
stimulation  is  often  required.  The  same  methods,  with  general  tonic 
treatment,  are  frequently  needed  during  convalescence.  Modified 
small-pox  generally  requires  little  treatment  of  any  sort,  especially  after 
the  initial  stage  is  past. 

'  Loc.  oi.,  :u\. 


376  THE  DISEASES  OF  CHILDREN 

CHAPTER  VII 
VACCINIA.     VACCINATION 

Etiology  and  Pathology. — Vaccinia,  or  cow-pox,  is  an  infectious 
eruptive  disease  oftenest  seen  upon  the  udders  of  cows,  although  the 
horse  is  occasionally  subject  to  it.  Its  identity  with  small-pox  has  been 
disputed,  but  it  seems  most  probable  that  it  is  this  disease  modified  by 
its  occurrence  in  cattle.  The  inoculation  of  the  human  subject  with 
the  vaccine  virus  is  called  vaccination.  Although  it  had  long  been  a 
popular  belief  that  the  contracting  of  cow-pox  from  animals  prevented 
small-pox  in  man,  and  although  the  inoculation  with  the  vaccine  virus 
had  been  practised  previously,  yet  the  careful  testing  of  the  actual 
protective  power  and  the  urging  of  the  procedure  upon  the  medical 
profession  is  to  be  credited  to  Jenner.^ 

The  microorganism  of  vaccinia  is  not  definitely  known.  Various 
bacteria  have  been  discovered  in  the  lymph,  and  certain  bodies,  apparently 
protozoa,  and  entitled  "cytoryctes,"  have  been  found  in  the  serum  of  the 
vesicle  by  Guarnieri^  and  others.  Paschen^  claims,  however,  that  these 
are  only  end-products,  and  that  the  germ  is  much  more  minute  and  still 
undetermined.  This  is  sustained  by  Prowazek  and  Miyazi.^  Whatever 
its  nature,  it  must  be  the  same  as  that  of  variola. 

Vaccination  was  originally  performed  with  matter  taken  from  a  cow- 
pox  sore  occurring  upon  a  human  being.  Shortly  afterward  the  virus  ob- 
tained directly  from  the  cow  was  employed.  Later  both  bovine  and  hu- 
manized lymph  were  extensively  used,  but  of  recent  years  the  former  has 
entirely  supplanted  the  latter.  This  has  removed  the  possible  danger  of 
transmitting  disease,  especially  syphilis,  by  the  use  of  humanized  lymph. 
The  lymph  may  be  dried  upon  ivory  points  or  quills,  but  is  preferably, 
and  now  usually,  mixed  with  glycerin  and  preserved  in  glass  tubes; 
the  so-called  "glycerinated  lymph."  Glycerin  destroys  all  pyogenic 
bacteria  if  thorough  ripening  has  been  allowed.  Noguchi^  has  devised 
a  method  of  inoculation  of  the  testicles  of  rabbits  and  young  bulls  with 
a  virus  free  from  bacteria,  and  of  making  cultures  from  the  inoculated 
organ.  In  this  way  virus  absolutely  free  from  foreign  germs  can  be 
produced. 

Age  for  Vacci nation. ^ — Regarding  the  age  when  vaccination  is 
best  performed  there  is  some  difference  of  opinion.  That  which  I  prefer 
is  about  3  or  4  months.  By  this  time  the  vigorous  infant  will  probably 
have  overcome  any  earlier  digestive  difficulties.  After  this  age  the  consti- 
tutional effect  of  vaccination  is  liable  to  be  greater.  Should  small-pox 
be  prevalent  vaccination  should  be  done  in  the  1st  month.  Other  cir- 
cumstances, too,  influence  the  decision,  and  an  occasion  should  be  selected 
when  the  infant  is  in  good  general  condition  and  free  from  eczema, 
and  when  the  weather  is  not  very  hot. 

Method. — It  has  been  largely  recommended  to  vaccinate  in  two  or 
three  different  spots  about  an  inch  apart,  on  the  ground  that  the  greater 

^  An  Inquiry  into  the  Causes  and  Effects  of  the  Variola;  vaccina",  etc.,  London, 
1798. 

2  Centralbl.  f.  Bakt.,  1894,  XVI,  299. 

3  Miinch.  med.  Wochenschr.,  1906,  LIII,  2391. 

4  Centralbl.  f.  Bakt.  und  Parasitenk.,  1914-15,  Orig.,  LXXV,  144. 

5  Arch,  of  Pediat.,  1915,  XXXII,  698. 


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VACCINIA.     VACCINATION  377 

the  number  of  lesions  the  less  will  be  the  subsequent  danger  of  contracting 
small-pox.  In  America  scarifying  in  a  single  spot  is  more  commonly 
employed.  (See  Protective  Power  of  Vaccination,  p.  380.)  The  locality 
usually  chosen  is  the  outer  surface  of  the  upper  arm  at  about  the  insertion 
of  the  deltoid  muscle,  or,  in  the  case  of  female  infants,  if  the  presence  of 
scarring  is  objected  to,  the  outer  surface  of  the  leg  shortly  below  the  knee. 
The  skin  should  be  vigorously  cleansed  with  soap  and  water  and  then 
with  alcohol,  and  the  hands  of  the  operator  disinfected.  A  needle 
previously  sterilized  by  being  boiled  or  by  holding  the  point  in  an  alcohol 
flame,  should  be  used  "to  make  on  the  skin  four  or  five  scratches  parallel 
and  close  together,  and  then  an  equal  number  crossing  them.  They 
should  be  only  deep  enough  to  scarify  the  epidermis  and  expose  the  blood- 
vessels, but  not  to  draw  blood,  lest  the  entrance  of  the  virus  be  prevented 
by  it.  The  whole  surface  of  scarification  should  not  exceed  one-quarter 
of  an  inch.  By  compressing  the  small  rubber  bulb  which  is  commonly 
sold  with  the  glass  tube  the  lymph  flows  out  upon  the  wound,  and 
may  then  be  gently  but  thoroughly  worked  into  the  scratches.  In 
place  of  the  needle  a  scarifier  may  be  employed,  as  used  for  the  cutaneous 
tuberculin  test.  Very  complete  and  satisfactory  outfits  are  now  fur- 
nished in  which  the  glass  tube  terminates  in  a  sharp  point  with  which 
the  scarification  may  be  done.  The  point  is  then  broken  off  and  the 
upper  end  of  the  tube  as  well,  the  rubber  bulb  fitted  and  the  virus  ex- 
pelled. The  wound  should  be  allowed  to  dry  for  15  or  20  minutes  and 
then  be  covered  with  salicylated  absorbent  cotton  bound  upon  it  with  a 
gauze  bandage,  and  made  firm  with  a  few  strips  of  rubber  adhesive 
plaster.  The  cotton  should  be  left  constantly  in  position  throughout 
the  whole  course  of  the  development  of  the  pock,  unless  the  vesicle 
ruptures  and  moistens  it  too  greatly,  or  an  unusual  degree  of  suppuration 
takes  place.  In  this  case  the  application  of  fresh  cotton  is  needed. 
During  the  vaccination-period  the  infant  should  be  sponged  but  not 
placed  in  the  tub,  in  order  that  the  cotton  shall  not  become  wet.  Vacci- 
nation shields  are  not  to  be  recommended. 

It  has  been  advised  by  several  writers  to  vaccinate  by  means  of  intra- 
dermal injections,  since  in  this  way  the  scarring  is  absent  or  lessened. 
The  method  has  not  appeared  to  possess  sufficient  real  advantage  and 
has  not  been  widely  adopted. 

Course  of  Normal  Vaccination  (Fig.  82). — The  development  and  the 
histological  structure  of  the  vaccine  lesion  is  practically  identical  with  that 
of  small-pox.  (See  p.  365.)  Except  for  the  scratch  marks  the  skin  shows 
no  alteration  until  the  3d  or  sometimes  the  4th  or  5th  day.  This  closes 
what  may  be  called  the  period  of  incubation.  A  small,  faintly  red  macule 
now  appears  and  marks  the  beginning  of  the  period  of  crwplion.  Infiltra- 
tion quickly  changes  this  into  a  papule  surrounded  by  a  narrow  rod  areola. 
By  the  5th  day  of  the  vaccination  a  small  vesicle  appears  in  the  papule, 
and  by  the  6th  day  this  covers  the  scarified  area  and  is  filled  with  trans- 
parent lymph.  The  vessel  is  multilocular  in  structure  and  umbilicated,  re- 
.  sembling  that  of  small-pox.  By  t  he  7th  or  8th  day  it  reaches  its  maximum 
size,  is  of  a  pearly-grey  color  and  half  an  inch  (1.3  cm.)  or  loss  in  diamotor. 
The  areola  aboiit  it  then  commoncos  to  extend  in  width  and  the  lynijih 
to  become  cloudy  tiirougli  the  pioihictioii  of  pus  cells  in  it.  The  vesicle^ 
is  now  tense  and  yellow,  the  umbilication  disappears,  the  areola  grows 
still  more  pronounced,  and  by  the  9th  day  the  underlying  and  surround- 
ing tissues  are  red  and  swollen.  On  the  10th  or  Utli  ilay  dosiccation 
begins   and   the  surrounding  swelling   and    redness    dhninish    rapidly. 


378 


THE  DISEASES  OF  CHILDREN 


The  pock  is  now  flaccid  and  depressed,  and  rapidly  dries  into  a  dark 
crust.  This  crust  is  often  fully  formed  by  the  15th  day,  although  it 
does  not  fall  off,  unless  forcibly  removed,  until  about  the  end  of  the  3d 
week  or  later,  when  it  leaves  a  reddish  scar  which  afterward  becomes 
white,  depressed,  and  characteristically  pitted  (Fig.  83). 

Certain  symptoms  attend  the  vaccinal  eruption,  but  less  often  in 
the  early  months  of  life  than  later.  Some  itching  and  tension  may  occur 
when  the  papule  is  developing  and  still  more  when  the  pustule  is  at  its 
height.     About  the  5th  day  after  vaccination  there  is  in  many   cases 


Fig.  83. — Scars  of  Vaccination. 
Four  good  scars  from  an  infantile  vaccination,  showing  pitting  and  depression  beneath 
surrounding  skin.  Patient  contracted  in  adult  life  a  mild,  modified  smallpox  for  which 
he  was  treated  at  the  Philadelphia  Hospital  for  Contagious  Diseases.  Stains  of  smallpox 
lesions  visible  in  the  photograph.  (Welch  and  Schamberg,  Acute  Contagious  Diseases, 
1905,  PI.  II.) 

slight  fever  of  a  remittent  type,  which  gradually  increases,  reaching  its 
maximum  of  102°  to  104°F.  (38.9  to  40°C.)  on  the  8th  or  9th  day  with 
the  full  development  of  the  pustule  and  then  falling  quickly  or  gradually 
(Fig.  84).  There  is  fretfulness,  restlessness,  loss  of  appetite,  malaise  and 
occasionally  vomiting.  The  axillary  or  the  inguinal  glands  may  be 
swollen  and  tender  when  the  pustule  is  at  its  height.  A  decided  leuco- 
cytosis  is  present  (Sobotka).^ 

Irregularities  in  the  Course  of  Vaccination. — Not  infrequently 
the  incubation  is  unduly  prolonged,  the  lesion  not  making  its  appearance 

^  Zeitschr.  f.  Heilk.,  1893,  XIV,  349. 


VACCINIA.      VACCINATION 


379 


under  a  week  or  even  more  after  vaccination.  Less  often  incubation 
is  shortened  and  the  vesicle  is  visible  by  the  3d  day.  The  fever^  is 
in  some  cases  decidedly  high.  The  local  process  may  be  severe,  the  lesion 
becoming  unusually  large,  and  not  infrequently  having  several  small 
secondary  vesicles  developing  in  the  surrounding  tissue.  These  generally 
run  an  abortive  course. 

In  rare  cases  a  spontaneous  generalized  vaccinia  is  witnessed  (Fig.  85). 
In  this  condition  secondary  vesicles  are  found  on  various  parts  of  the 
body.  They  first  appear  at  the  time  of  the  maturation  of  the  original 
pock,  or  shortly  before  or  after  this,  and  then  continue  to  occur  in  succes- 
sive crops,  maturing  rapidly,  the  whole  process  extending  occasionally 


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F'iG.  84. — Vaccination. 
Marie  B.,  aged  21  months.     Dec.  29.  vaccinated;  Jan.  3,  vomited;  Jan.  4,  lesion  well 
developed;  Jan.  5,  arm  very  sore,  axillary  glands  swollen;  Jan.  6,  fretful  and  restless  during 
night,  arm  unchanged;  Jan.  7,  arm  much  less  swollen  and  child  bright. 

over  several  weeks,  and  consequently  exhibiting  at  the  same  time  dif- 
ferent stages  of  development.  Generally  they  leave  no  scars,  but  to  this 
there  are  exceptions.     In  some  cases  the  lesions  strongly  suggest  variola. 

A  vaccinia  generalized  by  autoinoculation  likewise  may  occur,  the 
child  reinoculating  itself  in  various  places  Ijy  scratching  or  in  other  ways. 
The  spots  are  usually  very  few  in  number.  If  eczema,  for  instance,  is 
present  the  region  involved  may  become  infected  from  the  vaccine  pustule 
and  a  secondary  large  confluent  lesion  develop.  The  lesions  have  been 
seen  in  the  mouth,  throat,  eye,  tongue,  nose  and  elsewhere.  The  title 
"generalized  vaccinia"  is  better  reserved  for  the  spontaneous  form. 

Generalized  vaccinia  is  fortunately  rare,  inasmuch  as  it  may  affect 
the  entire  system  severely  and  even  cause  death.     Huddleston'  was  able 

>■  Med.  News,  1901,  LXXIX,  370. 


380 


THE  DISEASES  OF  CHILDREN 


to  collect  from  medical  literature  but  50  reported  cases  of  generalized 
vaccinia,  most  of  them  of  the  spontaneous  form,  7  of  which  terminated 
fatally.  Fatal  cases  have  since  been  reported  by  others  (d 'Astros;^ 
Hegler2). 

Spurious  Vaccination. — Particularly  in  subjects  vaccinated  not  for 
the  first  time  a  lesion  may  appear  w.hich  is  not  evidence  of  a  genuine 
vaccinal  infection.  In  some  such  cases  a  vesicle  develops  promptly 
and  rapidly  produces  pus  and  crusts,  the  latter  by  the  7th  or  8th  day. 
The  attendant  itching  is  severe.  In  some  cases  merely  a  papule  forms, 
or  a  very  small  vesicle  upon  this,  no  scar  resulting.     In  others  a  projecting, 


Fig.  85. — Spontaneous  Generalized  Vaccinia. 
Primary  vaccination  below  the  knee. 


dark-red,  slightly  granular  "raspberry  excrescence"  may  develop  instead 
of  the  normal  vesicle.  In  these  conditions  it  is  probable  that  little,  if 
any,  protective  power  results,  and  revaccination  should  be  practised. 

Revaccination  and  Insusceptibility  to  Vaccination. — As  with 
all  infectious  diseases  certain  individuals  are  temporarily  or  permanently 
immune.  Repeated  vaccinations  durmg  infancy  may  fail  to  take.  In 
all  such  cases  further  attempts  should  be  made  at  intervals,  as  there  is  no 
certainty  that  the  insusccptibilit}^  will  be  lasting. 

Protective  Power  of  Vaccination. — Nothing  except  the  wide- 
spread employment  of  vaccination  can  account  for  the  great  diminution 
in  the  number  of  cases  of  small-pox.     Not  only  do  general  statistics 

1  Marseille  med..  1912,  XLIX,  149. 

2  Dermatolog.  Wochenschr.,  1914,  LVIII,  Erganzungsh.,  29. 


VACCINIA.      VACCINATION 


381 


throughout  the  civilized  world  prove  this  beyond  cavil,  but  the  instances 
oi  severe  local  outbreaks  of  small-pox  in  regions  where  vaccination  had 
been  neglected  show  both  the  importance  of  the  procedure  and  that  the 
virulence  of  small-pox  has  by  no  means  lessened  with  the  passing  years. 
In  countries  where  vaccination  has  been  made  compulsory  its  value  is 
particularly  marked.  The  accompanying  illustration  (Fig.  86)  shows 
graphically  the  result.  After  the  introduction  of  compulsory  vaccina- 
tion into  Prussia  in  1875,  the  average  annual  death-rate  from  small-pox 
fell  to  1.91  per  100,000  of  the  population,  whereas  from  1816  to  1870  it 
had  ranged  from  7.32  to  62.0  per  100,000.  In  Austria  without  such 
regulation  the  contemporaneous  death-rate  from  it  was  unaffected  (Welch 


PRUSSIA,   1847-1897. 

SMALL-POX  DEATHS  PER  MILLION  OF  POPULATION. 


sif issilllSiiiSiiiiiiiii  S 

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AUSTRIA,  1847-1897. 

SMALL-POX  DEATHS  PER  MILLION  OF  POPULATION. 


■*  ■«•  -f  .-i  o  .f^  ,-5  ..o  *r.  tfj  trt  .^  »; 

1800 
1801 
1802 
1803 
1804 
1805 
1800 
1867 
1808 
1809 
1870 
1871 
1872 

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1875 
1876 
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1880 
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inni  II II  in  ii  ii  ii  i  ii  ii  ii  ii  ii  n  g  ii  n  i  ii  n  ii  ii  ii  u 

milli..ll    III 

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liUllllllllUllillllllillll 

3rFsESH?Si2fi^ 

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5s5gs;iSi'^^- 

Fig.  86. — Tables  Showing  the  Decline  of  Sm.\ll-po.\  i.n  Germany  after  the 
Enaction  of  Compulsory  Vaccin.\tion  in  1874. 
Smallpox  mortality  is  compared  with  that  of  Austria.     (Welch  and  Schamberg,  Acute 
Contagious  Diseases,  1905,  123.) 

and  Shamberg) .  ^  In  the  Philippine  Islands  where  small-pox  had  previouslj' 
been  rampant,  with  an  average  annual  mortality  of  at  least  6000  cases 
in  the  six  provinces  near  Manila,  not  a  single  vaccinated  person  died  after 
systematic  vaccination  was  established  in  1907  (Heiser  and  Oleson).- 

The  duration  of  the  protective  power  varies.  With  some  persons  it  is 
complete  and  permanent,  while  with  others  it  gradually  lessens,  and  modi- 
fied or  even  typical  small-pox  is  acquired  if  exposure  occurs,  the  severity 
of  this  depending  to  some  extent  upon  the  time  which  has  elapsed  since 
vaccination  was  performed.  The  naming  of  an  average  duration  of 
protective  power  is  impossible.  Welch  and  Schamljerg''  estimate  that 
absolute  protection  by  vaccination  in  infancy  is  found  in  only  about  25 
per  cent,  of  the  cases.     It  is  safe  to  maintain  that  rovaccination  should 

'  Loc.  cit.,  I2:i. 

■^  U.  S.  Publ.  Health  Rep.,  1911,  XXVI,  pt.  1,  277. 

'  Loc.  cit.,  115. 


382  THE  DISEASES  OF  CHILDREN 

always  be  performed  at  the  age  from  5  to  7  years,  again  at  puberty,  and 
again  at  the  beginning  of  adult  life.  Certainly,  too,  if  small-pox 
becomes  prevalent,  all  those  who  have  been  certainly  exposed  should  be 
revaccinated  at  once,  and  everyone  who  has  not  had  a  successful  vac- 
cination within  5  years  should  submit  to  it.  If  the  attempt  at  revaccina- 
tion  fails  it  should  be  repeated.  If  this  also  fails,  we  cannot,  of  course, 
be  certain  that  immunity  exists,  but  it  is  reasonable  to  assume  it. 

Although  it  is  manifestly  not  to  be  expected  that  successful  revacci- 
nation  in  a  partially  protected  person  will  produce  a  lesion  exactly 
similar  to  that  of  a  primary  vaccination,  yet  it  should  certainly  possess 
some  general  resemblance  to  the  original.  The  character  and  size  of 
the  primary  scar  has  some  bearing  upon  the  degree  of  protection  offered. 
The  statistics  of  the  Hospital  for  Contagious  Diseases  of  Philadelphia, 
from  1891  to  1903  (Welch  and  Schamberg),^  give  a  mortality  from  small- 
pox of  6.55  per  cent,  in  patients  with  one  good  scar  from  vaccination  in 
infancy,  14.39  per  cent,  in  those  with  one  fair  scar  and  24.83  per  cent, 
in  those  with  one  poor  scar.  The  degree  of  protection  has  been  generally 
believed  to  be  in  proportion  to  the  number  of  scars;  hence  the  custom 
prevalent  in  Europe  of  vaccinating  in  several  places.  The  statistics  of 
the  Philadelphia  Hospital  for  Contagious  Diseases  do  not  entirely  sup- 
port this  view,  the  quality  rather  than  the  number  of  the  marks  appear- 
ing to  exert  the  greatest  influence. 

Complications  and  Sequels. — An  unusual  degree  of  inflammation 
may  occur  in  the  sore,  depending  upon  trauma  or  a  depreciated  state  of 
health,  or  oftener  upon  infection  by  pyogenic  germs.  Deep  ulceration 
may  follow,  the  entire  thickness  of  the  skin  at  the  site  of  the  lesion  being 
destroyed,  or  a  diffuse  cellulitis  or  even  gangrene  developing.  Such 
an  occurrence  is  nearly  always  due  to  an  infection  of  the  wound  at  the 
time  of  vaccination  or  later;  rarely  to  any  trouble  with  the  virus  itself. 
An  attack  of  eczema  may  sometimes  be  produced  by  vaccination.  Urti- 
caria is  a  not  infrequent  complication,  and  a  rubeoloid  erythema  is  still 
oftener  seen,  developing  during  the  maturation  of  the  pock.  This  may 
be  localized,  or  may  cover  much  of  the  body.  Other  cutaneous  disor- 
ders have  occasionally  been  reported  as  complications  or  sequels,  among 
them  impetigo,  lichen,  ecthyma,  furunculosis,  psoriasis,  pemphigus  and 
miliaria.  In  rare  cases  the  pocks  and  the  surrounding  tissue  may 
become  hemorrhagic.  Exceptionally  a  general  sepsis  may  follow  vaccina- 
tion, arising  from  the  infection  of  the  wound.  An  interesting  small  epi- 
demic of  this  is  described  by  Brouardel.^  Erysipelas  was  formerly  a 
common  and  much  dreaded  complication,  but  with  improved  aseptic 
methods  it  has  become  very  rare.  Lotz^  found  but  2  deaths  reported 
from  it  in  1,252,554  vaccinations.  Syphilis  has  rarely,  but  undoubtedly, 
been  communicated  by  vaccination.  The  employment  of  bovine  lymph 
entirely  avoids  the  chance  of  this.  The  transmission  of  tuberculosis  is 
perhaps  possible  with  human  lymph,  but  the  danger  with  glycerinated 
lymph  from  calves  does  not  exist.  Tetanus  has  undoubtedly  been  given 
by  vaccination,  the  germs  either  entering  accidentally  an  ill-cared-for 
wound,  or  being  contained  in  an  infected  lymph.  Although  McFarland* 
collected  95  cases  from  medical  literature,  the  occurrence  of  this  disease  as 
a  complication  is  relatively  very  rare.     Proper  supervision  of  the  produc- 

1  Jjfif*    /*')  f     t7 

2  Twentieth  Century  Pract.  of  Med.,  XIII,  534. 
^  Ref.  Brouardel,  loc.  cit.,  534. 

^  Proceed.  Phila.  Co.  Med.  Soc,  1902,  XXIII,  1G6. 


VARICELLA  383 

tion  of  the  lymph  used  will  avoid  it  entirely,  so  far  as  the  contamination 
of  the  lymph  is  concerned.  There  is,  it  is  true,  alwaj^s  a  possibility'  of 
its  production  by  the  entrance  of  germs  from  the  air  into  the  vaccination- 
wound;  but  much  less,  with  proper  care,  than  exists  in  the  case  of  any 
slight  wound  which  has  been  left  exposed  to  the  air. 

Mortality. — The  mortality  from  vaccination  is  a  negligible  figure 
if  proper  precautions  are  taken.  According  to  Klibler^  there  were  113 
deaths  in  approximately  32,000,000  vaccinations  (0.000035  per  cent.) 
done  in  Germany  during  the  13  years  from  1885  to  1897,  and  many  of  these 
were  directly  traceable  to  neglect. 

Treatment. — The  treatment  of  the  vaccination  lesion  has  already 
been  described.  Should  fever  develop  a  mild  febrifuge  is  advisable.  In 
subjects  beyond  the  1st  year  of  life  the  vaccinated  limb  should  be  used 
with  moderation.  If  an  unusual  degree  of  inflammation  occurs  the 
dressing  must  be  removed  and  the  wound  treated  on  general  surgical 
principles. 


CHAPTER  VIII 
VARICELLA 
(Chicken-pox) 


Although  described  much  earlier,  varicella  was  first  differentiated 
clearly  from  variola  by  Fuller  in  1730-  and  bj^  Heberden  in  17(37.^  There 
are  probably  still  some  who  consider  it  only  a  form  of  variola,  but  the 
very  great  majority  of  writers  of  the  present  day  believe  it  to  be  an  en- 
tirely independent  disease,  basing  this  opinion  on  its  appearance  in  dis- 
tinct epidemics  and  its  entire  failure  to  protect  from  small-pox  or  to  be 
prevented  by  vaccination. 

Etiology.  Predisposing  Causes. — Age  is  the  most  important  of  these, 
varicella  being  preeminently  a  disease  of  infancy  and  especially  of  early 
childhood.  It  is  observed  in  the  first  months  very  much  oftener  than 
either  scarlet  fever  or  measles  (Pridham).'*  It  has  even  been  described 
as  occurring  congenitally.  Although  the  susceptibility  lessens  greatly 
after  the  age  of  10  years  yet  the  statements  of  many  writers  up  to  quite 
recent  periods,  to  the  effect  that  it  is  never  seen  in  adult  life,  are  contrary 
to  the  general  experience.  Thus,  Wanklyn^  found  that  of  200  cases  of 
varicella  16.7  per  cent,  were  in  persons  over  18  years  of  age.  Such 
frequent  occurrence  after  childhood  is,  however,  unusual. 

Seasons,  climate  and  sex  exert  no  predisposing  influence.  The  indi- 
vidual susceptibility  in  childhood  is  very  great,  most  of  those  exposed 
contracting  it.  Not  infreciuently,  however,  some  children  seem  to  be 
entirely  immune.  That  so  few  adults  are  attacked  is  probably  in  part 
due  to  the  fact  that  most  persons  have  already  had  the  disease  in  early 
life.  It  is  oftener  endemic  than  epidemic.  Thus  in  someTj^ears  in  large 
cities  great  numbers  of  cases  are  seen,  in  others  much  fewer;  yet  it  is 
always  j)resent  to  some  extent. 

1  Gcschichte  dor  Pockon  und  dor  Inipfuiip,  1901,  364. 

2  (ice,  K(>vnolds  Svst.  Med.,  Aincr.  Ed.  1879,  I,  124. 

3  Mod.  Transac.  Col.  of  Phv.s.,  London,  1768,  I,  427. 
*  Brit.  Med.  Journ.,  191.S,  I,  10."j4. 

6  Brit.  Med.  Journ.,  1902,  II,  47. 


384  THE  DISEASES  OF  CHILDREN 

Exciting  Cause. — This  is  undoubtedly  a  germ,  the  nature  of  which  is,  as 
yet,  unknown,  although  various  microorganisms  have  been  reported.  De 
Korte^  described  an  ameba-like  body  present  in  the  vesicles,  and  Greeley- 
a  sporothrix  which  corresponds  to  the  cytoryctes  variolse.  Further 
study  is  needed.  The  method  of  transniissio7i  is  not  definitely  known. 
Although  the  disease  is  in  the  large  majority  of  instances  acquired  by  di- 
rect contact  or  by  short  exposure  in  the  vicinity  of  an  affected  child,  it  is 
not  infrequently  conveyed  mediately  through  a  third  unaffected  person  or 
through  articles  of  clothing  and  the  like.  It  is  probable  that,  next  to 
variola,  chicken-pox  is  the  one  of  the  infectious  fevers  most  readily  trans- 
mitted mediately.  Numerous  inoculation  experiments  have  been  made 
with  the  serum  of  the  vesicles,  and  Steiner^  claimed  to  have  succeeded 
8  times  in  10  cases,  but  his  results  are  exceptional,  and  the  disease  is  seldom 
transmissible  in  this  way.  Buchmiiller*  had  negative  results  in  30  cases. 
The  readiness  with  which  varicella  is  spread  in  schools  shows  conclusively 
that  the  period  of  infectiousness  commences  at  the  very  beginning  of  the 
eruptive  stage,  and,  there  is  reason  to  believe,  even  before  this.  It  is 
uncertain  how  long  it  continues,  or  whether  the  virus  is  present  in  the 
crusts,  but  the  duration  of  life  is  probably  short.    . 

Pathological  Anatomy. — The  characteristic  lesions  consist  solely 
of  macules  and  papules  developing  later  into  vesicles,  which  occupy 
only  the  upper  layer  of  the  epithelium  and  are  unilocular,  or  often 
multilocular  as  can  be  demonstrated  by  pricking  them  with  a  needle. 
The  areola  often  surrounding  them  is  formed  by  distended  capillaries 
and  slight  cellular  infiltration.  The  fluid  contents  are  of  clear  serum 
which  later  becomes  cloudy  and  contains  a  few  leucocytes.  In  some  of 
the  vesicles,  under  the  influence  of  irritation  or  infection,  the  process 
extends  deeper,  a  large  exudation  of  leucocytes  takes  place,  and  the 
corium  is  destroyed  and  replaced  by  scar  tissue. 

Symptoms.  Ordinary  Form. — The  stage  of  incubation  is  somewhat 
variable,  averaging  about  14  days,  but  being  sometimes  less,  and  extend- 
ing often  up  to  3  weeks ;  in  Steiner's  inoculation-cases  always  8  days.  The 
stage  of  invasion  is  usually  absent,  although  occasionally  there  may  be  slight 
malaise,  moderate  fever,  and  general  aching,  present  for  24  hours  or 
less  before  the  rash  develops.  At  times  a  widespread  prodromal  erythema 
of  a  scarlatiniform  or,  more  rarely,  morbilliform  type  is  seen  a  few  hours 
before  the  appearance  of  the  characteristic  rash.  This  is  generally 
most  marked  on  the  trunk  and  lower  limbs.  As  a  rule,  however,  the 
first  symptom  observed  is  the  fully  developed  eruption.  Tracing  the 
history  of  the  individual  lesion  from  its  onset,  there  is  first  found  a  red 
macule  disappearing  on  pressure  and  of  the  size  of  a  pin-head  to  that  of 
a  split-pea  or  larger.  Within  a  very  few  hours  a  small  vesicle  filled  with 
clear  liquid  develops  upon  the  centre  of  the  macule.  In  a  much  smaller 
number  of  lesions  a  small  papule  forms  upon  the  macule,  and  a  vesicle 
then  very  quickly  develops  on  the  apex  of  this.  The  vesicle  rapidly 
enlarges  and  reaches  its  height  within  a  day  cr  less  from  its  first  ap- 
pearance. In  shape  it  is  round  or  oval,  and  in  size  very  variable,  but 
averages  that  of  a  split-pea  (Fig.  87).  A  narrow  red  areola  often  sur- 
rounds it.     Desiccation  now  begins  at  once,  the  prominent  rounded  surface 

1  Practitioner,  1905,  LXXIV,  50. 

2  New  York  Med.  Rec,  1914,  LXXXVI,  204. 

3  Wien.  med.  Wochenschr.,  1875,  XXV,  304. 

*  Mittheil.  des  Verein  der  Aerzte  in  Theiermark,  1886.  Ref.  Swoboda,  Pfaundler 
und  Schlossmann  Handb.  der  Kinderh.,  1906,  I,  b,  724. 


VARICELLA 


385 


flattening  a  little,  and  the  contents  becoming  somewhat  turbid.  Slight 
iimbilication  is  common  at  this  stage.  After  12  to  24  hom's  more  the 
areola  disappears,  and  a  yellowish  crust  begins  to  form  and  is  complete 
in  from  3  to  4  days.  It  darkens  and  finally  falls  off  after  a  period  varying 
from  5  or  6  days  to  2  or  3  weeks  leaving  the  skin  slightly  reddened  for  a 
time. 

This  is  the  course  in  the  typical  lesion.  The  majority  of  the  lesions, 
how^ever,  do  not  mature.  Many  macules  never  develop  further,  and  are 
no  longer  visible  after  a  few  hours,  while  a  few  pass  into  the  papular 
stage,  continue  so  for  a  day  or  two  and  then  disappear.     Many  vesicles 


Fig.  87. — Eruption  of  Chicken-pox,  Showing  the  Pearly  Vesicles. 
From  a  case  in  the  Children's  Hospital  of  Philadelphia. 

never  grow  larger  than  the  head  of  an  ordinary  pin  and  dry  very  rapidlj\ 
On  the  other  hand  vesicles  are  often  larger  than  the  average,  and  require 
a  longer  time  for  full  development  and  drying. 

The  rash  generally  makes  its  first  appearance  on  the  face  and  back, 
less  often  on  the  limbs.  It  spreads  over  the  body  from  above  downward, 
but  so  rapidly  that  the  discovery  of  any  sequence  is  difficult.  All  parts 
of  the  surface  are  attacked,  including  the  palms  and  soles  and  the  mucous 
membrane  of  the  mouth  and  throat,  especially  the  hard  palate;  of  the 
nose  and  the  genital  organs;  and  rarely  even  of  the  larynx  and  trachea 
and  the  eyes.  Upon  mucous  membranes  the  covering  of  the  vesicle 
soon  ruptures  under  the  influence  of  moisture,  and  the  lesion  suggests 
that  of  aphthous  stomatitis. 

The  numl)er  of  lesions  varies  greatly  from  perhaps  a  dozen  up  to 
hundreds.     A  case  of  average  intensity  presents  from  25  to  75.     In  mild 

25 


386 


THE  DISEASES  OF  CHILDREN 


cases  there  may  be  scarcely  a  dozen .  They  are  generally  most  nmnerous  on 
the  trunk,  especially  the  back.  The  forearms,  hands,  legs  and  feet  are 
involved  to  a  decidedly  less  extent.  The  head  is  generally  less  affected 
than  other  regions  but  there  are  nearly  always  some  lesions  on  the  scalp. 
All  the  vesicles  which  mature  are  generally  fully  crusted  in  from  6  to.'  8 
days  from  the  first  appearance  of  the  eruption. 

One  of  the  principal  characteristics  of  the  eruption  is  its  appearance 
in  successive  crops  during  3  or  4  days  in  the  regions  already  involved. 
As  a  result  of  this  fact,  and  of  the  failure  of  so  much  of  the  rash  to  mature, 


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Fig.   88. — Mild  Varicella. 

Eruption    developed    on    Dec.    17.     Practically   no    other 


Philip   A.,  aged  2  years, 
symptoms. 

Fig.  89. — Moderately  Severe  Varicella  with  Unusually  Well-developed 

Eruption. 
Caroline  R.,  aged  8  years.     Feb.  25,  a  few  vesicles  on  the  body;  Feb.  27,  child  dull; 
very  numerous  vesicles,  including  a  large  number  on  the  tongue;  Feb.  28,  improving. 

lesions  in  all  stages  of  development  from  macules  to  crusts  may  be  seen 
side  by  side.  When  a  vesicle  has  become  infected,  or  has  been  greatly 
irritated  by  the  rubbing  of  the  clothing,  decided  suppuration  is  liable 
to  take  place,  and  an  inflamed  area  is  produced,  covered  by  a  scab 
which  conceals  pus  beneath  it.  The  healing  is  thereby  delayed  and 
white  scars  may  be  left  similar  to  those  of  variola. 

Symptoms  attending  the  eruption  are  slight  or  absent.  Moderate  fever, 
averaging  101°  to  102°F.  (38.3°  to  38.9°C.)  may  be  present  during  2  or  3 
days  in  well-developed  cases,  but  generally  falls  gradually  to  normal  in  1 
or  2  days.  It  is  higher  and  lasts  longer  if  the  attack  is  severe  (Figs.  88 
and  89).  There  may  be  some  loss  of  appetite  and  disturbance  of  sleep. 
Considerable  itching  of  the  skin  is  often  present.     The  blood  shows  no 


VARICELLA 


387 


characteristic  alterations.  The  effect  upon  the  polymorphonuclear 
and  mononuclear  cells  respectively  appears  to  be  inconstant  (Weill 
and  Decos/  Xobecourt  and  Merklen;-  Mensi^). 

Variations  from  the  Ordinary  Course. ^ — To  be  mentioned  here  are 
only  those  variations  which  may  be  considered  uncommon.  Among 
unusual  prodromes  are  vomiting,  delirium,  convulsions,  somnolence 
and  severe  headache  and  backache.  I  have  known  the  latter  in  the  case 
of  an  adult  to  suggest  variola  very  strongly.  Blood-stained  stools  have 
also  been  reported. 


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Fig.  90.  t^i«-  91- 

Fig.  90. — Hemorrhagic  Varicella. 
Elizabeth  G.,   aged   iM  years.     May  16,  vesicles  appearing  on  the  back;   May   19, 
eruption  abundant  and  widespread;  May  22,  eruption  very  profuse  and  infiltrated  with 
blood;  May  23,  removed  from  hospital  on  account  of  pertussis  developing. 
Fig.  91. — Varicella  Gangrenosa. 
Occurring  in  an  infant  of  22  months,  a  patient  in  the  Children's  Hospital  of  Philadelphia. 
Diphtheria   followed    by  measles,  and  in  a  few  days  by  varicella.     Large  vesicles,  some 
sloughing,  developed  on  whole  body,  especially  the  head  and  back.     Death. 

Distinct  variations  of  the  cutaneous  lesions  may  be  seen  in  the  eruptive 
stage.  The  prodromal  erythema  may  sometimes  cotitinuc  into,  or 
first  appear  during,  the  eruptive  period.  A  confluent  varicella  is  very 
exceptionally  observed,  in  which  the  lesions  are  situated  on  a  red,  swollen 
base  common  to  them  all,  and  are  so  closely  placed  that  they  almost 
touch.  Til  is  is  especially  marked  on  the  forehead  and  back,  while 
elsewhere  the  discrete  character  of  the  lesions  is  apparent.  The  eyes 
are  closed  by  the  greatly  swollen  eyeHds,  the  fever  is  high,  the  puhe 

1  Journ.  dc  phys.  ct  de  path.  KC«n..  1902.  IV,  .'iOt. 

=  .Joiirn.  de  phvsiol.  ct  dc  pathol.  p^n..  1901,  111.  439. 

3Gaz.  degli  cspcdal.  ct  dcili  clin.,  1912,  XX.XIIl,  1025. 


388  THE  DISEASES  OF  CHILDREN 

rapid,  and  the  patient  clearly  ill.  Such  cases  may  arouse  a  strong  suspicion 
of  small-pox. 

Hemorrhagic  varicella  (Fig.  90)  is  a  rare  form  characterized  by  effusion 
of  blood  into  the  vesicles  and  sometimes  from  the  gastroenteric  nmcous 
membrane  as  well.  I  have  seen  it  but  once  or  twice.  The  subject  has 
been  reviewed  by  Storrie^  and  others.  The  term  gangrenous  varicella 
has  been  applied  to  a  complicating  condition  (dermatitis  gangrenosa), 
which,  although  perhaps  seen  oftenest  in  connection  with  chicken-pox, 
may  occur  in  other  conditions  as  well.  It  develops  only  in  debilitated, 
cachectic  children.  Certain  of  the  vesicles,  under  the  influence  of 
pyogenic  infection,  enlarge  and  suppurate,  and  a  gangrenous  process 
develops  in  them  destroying  even  the  entire  thickness  of  the  skin.  Septic 
symptoms  and  death  are  liable  to  follow.  In  one  case  under  my  ob- 
servation the  bacillus  pyocyaneus  was  recovered  from  the  lesions.  In 
another  (Fig.  91)  the  disease  occurred  in  a  child  who  suffered  simul- 
taneously from  rubeola,  diphtheria  and  varicella.-  Bullous  varicella 
is  a  very  uncommon  variety  in  which  the  eruption  appears  in  the  form 
of  large  buWse  which  may  reach  an  inch  or  more  in  diameter  and  which 
oh  rupture  leave  a  painful  raw  area. 

Complications  and  Sequels. — These  are  few.  One  of  the  chief 
in  importance,  although  not  common,  is  nephritis,  which  develops 
oftenest  at  the  end  of  the  1st  or  during  the  2d  week  of  the  disease. 
It  is  of  an  acute  parenchymatous  nature,  the  urine  containing  albumin  and 
casts.  Recovery  generally  follows  promptly,  but  the  disease  may  be 
severe  enough  to  be  fatal,  or  may  become  chronic.  A  varicellous  laryn- 
gitis is  a  severe  and  sometimes  fatal  complication  rarely  seen.  It  pro- 
duces symptoms  of  croup  and  may  require  intubation.  Multiple  arthritis 
occurring  during  or  at  the  close  of  the  eruptive  period  has  repeatedly 
been  described.  It  may  be  serous  or  purulent  in  character.  Anemia 
is  a  not  infrequent  sequel.  Varicella  may  be  combined  with  other  infec- 
tious diseases,  such  as  measles,  rubella,  pertussis,  scarlet  fever,  diphtheria, 
vaccinia,  tuberculosis,  and  even  variola.  Erysipelas,  too,  may  develop 
through  infection  of  the  lesions. 

Among  other  conditions  reported  as  occasionally  complicating  or 
following  varicella  are  pneumonia,  pleurisy,  retention  of  urine  the  result 
of  swelling  of  the  prepuce,  osteomyelitis,  otitis,  thyroiditis,  symmetrical 
gangrene,  appendicitis,  multiple  sclerosis,  chorea,  polioencephalitis, 
myelitis,  abscesses,  furunculosis,  subcutaneous  emphysema  and  adenitis. 
The  connection  of  many  of  these  with  the  attack  of  varicella  seems  prob- 
ably entirely  accidental.  I  have  seen  one  case  of  fatal  purpura  hemor- 
rhagica occur  as  a  sequel. 

Relapse  and  Recurrence. — Relapse  is  certainly  very  rare.  Comby' 
observed  it  in  one  instance  15  days  after  the  drying  of  the  vesicles. 
Dawes-*  found  4  relapses  in  30  cases  of  the  disease;  but  such  a  frequency 
is  certainly  most  exceptional.  A  few  other  instances  are  reported  in 
medical  literature  which  may  properly  be  placed  in  this  category. 

Recurrence  is  also  extremely  uncommon.  One  attack  protects  from 
a  second  in  nearly  every  instance.  In  524  cases  of  the  disease  observed 
by  Widowitz^  there  was  no  instance  of  it. 

1  Brit.  .Jour.  Child.  Dis.,  1914,  XI,  62. 

2  Univ.  Med.  Mag.,  1896,  Aug. 

3  Traits  des  mal.  de  I'cnf.,  Grancher,  etc.,  2d  Ed.,  I,  376. 
«  Albany  Med.  Ann.,  1902,  XXIV,  532. 

5  Wien.  klin.  Wochenschr.,  1909,  XXII,  1596. 


VARICELLA  389 

Prognosis. — Although  the  disease  is  one  of  the  least  serious  of  the 
infectious  disorders,  yet  fatal  cases  are  occasionally  seen.  Death  is 
usually  due  to  complications  such  as  nephritis,  erj^sipelas,  pneumonia 
and  gangrenous  dermatitis.  Varicella  of  the  larynx  has  a  high  mortality, 
as  has  hemorrhagic  varicella.  In  marantic  children  the  mere  develop- 
ment of  an  ordinary  varicella  may  not  be  without  danger.  I  recall  4 
such  infants,  sick  at  the  same  time  in  adjoining  beds,  in  all  of  whom 
progress  toward  recovery  was  apparently  checked  by  the  development 
of  chicken-pox,  and  a  fatal  issue  followed.  Very  exceptionally  in  unusu- 
ally severe  cases  death  may  occur  during  the  stage  of  eruption;  it  would 
seem  as  the  direct  result  of  the  toxemia  of  the  disease. 

Diagnosis. — As  a  rule  this  is  easy,  the  eruption  being  so  char- 
acteristic that  mistakes  cannot  arise.  It  rests  upon  the  absence  or  short 
duration  of  prodromal  symptoms,  the  absence  of  any  distinct  papular 
stage  in  the  great  majority  of  the  lesions,  the  situation  of  the  lesions  in 
the  superficial  portion  of  the  skin,  the  production  of  a  fully  formed  vesicle 
in  less  than  a  day  from  the  first  appearance  of  the  macule,  the  develop- 
ment of  the  vesicles  in  successive  crops  with  the  resulting  presence  at 
one  time  and  in  the  same  locality  of  lesions  in  all  stages,  and  the  drying 
without,  as  a  rule,  any  suppuration.  Yet  severe  cases  of  varicella,  espe- 
cially in  adults,  may  strongly  suggest  s7nall-pox,  and  on  the  other  hand, 
modified  small-pox  may  similarly  closely  resemble  varicella.  (See  Variola, 
p.  374.)  It  is  to  be  noted  that  as  a  rule  the  eruption  of  small-pox  selects 
especially  the  face  and  distal  portion  of  the  extremities;  that  of  chicken- 
pox  the  trunk.  To  this  there  are  exceptions.  As  regards  scarlet  fever, 
it  may  be  difficult  or  impossible  to  determine  in  some  cases  whether  one 
is  dealing  with  the  combination  of  this  with  varicella  or  with  the  scarla- 
tiniform  prodromal  rash  of  the  latter  disease. 

In  rare  instances  the  vesicular  form  of  impetigo  contagiosa  may  simu- 
late varicella  closely.  The  histor}^  of  the  attack,  with  the  study  of  symp- 
toms other  than  the  rash,  will  generally  eventually  lead  to  a  correct 
diagnosis.  In  other  cases  of  varicella  seen  for  the  first  time  during  the 
stage  of  desquamation,  the  resemblance  to  impetigo  may  be  decided. 
The  latter  disease,  however,  spreads  irregularly  as  a  result  of  auto- 
inoculation  by  the  fingers.  The  combination  of  acne  with  varicella  may 
also  obscure  the  diagnosis  for  a  time.  Pemphigoid  eruptions  may  at  first 
suggest  the  existence  of  varicella  with  unusually  large  vesicles. 

Treatment.  Prophylaxis. — Owing  to  the  mildness  of  the  disease 
it  is  seldom  thought  necessary  to  isolate  patients  suffering  from  it.  Yet 
in  the  case  of  schools,  in  hospitals  where  children  del)ilitatod  by  other 
diseases  are  present,  and  even  in  private  homes  where  there  are  delicate 
infants,  isolation  should  be  practised.  This  should  be  continued  as  long 
as  crusts  remain  on  the  l)0(ly;  i.e.  a  period  of  2  or  3  weeks.  Prophylactic 
inoculation  has  been  attempted  by  Kling,'  Hal)iiioff- and  others,  the  chil- 
dren being  inoculated  with  the  serum  from  a  fresh  varicella  vesicle.  The 
procedure  is  claimed  to  have  given  immunity  in  75  per  cent,  or  more  of 
the  cases. 

Treatment  of  the  Attack. — Usually  little  treatment  is  needed.  The 
patii^nt  should  be  confined  to  bed  and  given  a  light  diet  as  long  as  fever 
continues.  The  administration  of  a  febrifuge  is  advisable.  In  severe 
cases  the  treatnient  is  symptomatic.  The  urine  should  Ije  examined 
frequently  for  albumin.     Itching  may  be  allayed  by  the  application  of 

1  Berl.  klin.  Woch.,  1915,  LII,  13. 

2  Arch,  of  Pcdiat.,  1915,  XXXII,  G51. 


390  THE  DISEASES  OF  CHILDREN 

a  powder  of  camphor  and  zinc-oxide  or  of  a  thymolated,  ichthyolated,  or, 
in  older  children,  a  carbolated  ointment;  or  by  the  employment  of  warm 
baths.  Great  care  should  be  exercised  to  prevent  scarring  by  irritation 
through  scratching,  and  any  large  crusts  beneath  which  the  existence  of 
suppuration  is  suspected  should  be  removed  and  the  lesions  treated 
antiseptically.  During  convalescence  the  patient  ought  to  remain  in 
the  room  or  in  the  house.  Any  subsequent  anemia  or  other  sequels  or 
complications  require  treatment  appropriate  for  them. 


CHAPTER  IX   ' 
TYPHOID  FEVER 


Typhoid  fever,  now  widely  disseminated  and  universally  recognized, 
was  first  clearly  distinguished  from  typhus  fever  by  Gerhard,^  using 
his  own  and  Pennock's  cases,  only  as  long  ago  as  1837. 

Etiology.  Predisposing  Causes. — Climate  and  season  exert  a  certain 
influence,  the  disease  being  somewhat  more  prevalent  in  temperate  zones 
and  in  autumn  and  early  winter.  The  influence  of  age  is  very  decided. 
With  the  exception  of  a  very  few  observers,  it  is  only  within  about  the 
last  sixty  years  that  typhoid  fever  has  been  recognized  by  physicians 
as  occurring  in  childhood,  and  even  now  perhaps  most  authorities  claim 
that  it  is  uncommon  in  early  childhood,  and  very  rare  in  the  first  2  years 
of  life. 

All  statistics  indicate  that  the  periods  in  which  the  greatest  number  of 
cases  are  seen  are  later  childhood,  youth  and  early  adult  life.  There  is 
however,  considerable  variance  of  opinion  regarding  both  the  absolute 
and  the  relative  frequency  of  typhoid  fever  before  these  periods.  As  com- 
pared with  the  number  of  cases  observed  later  the  disease  is  decidedly 
less  frequent  up  to  the  age  of  5  years,  and  especially  in  the  first  2  years 
of  life.  That  it  cannot  be  called  "rare"  as  is  so  often  done  is  shown  by 
the  statistics,  among  others,  of  Barthez  and  Sanne'^  (90  cases  from  2  to  4 
years),  Schavoir^  (68  under  5  years  in  a  total  of  406  at  all  periods  of  life) 
and  Montmollin*  (15  under  2  years  in  295  children  under  15  years). 
The  statistics  of  general  hospitals  are  misleading,  because  children  are 
usually  treated  at  home  or  in  special  hospitals  for  children.  Even  the 
statistics  of  these  special  hospitals  by  no  means  represent  the  actual 
number  of  cases  in  infancy,  since  the  majority  of  infants  who  fall  ill  are 
cared  for  at  home.  This  is  especially  true  of  those  in  the  1st  year  of  life. 
Writing  in  1902  in  collaboration  with  Dr.  Maurice  Ostheimer^  we  de- 
tailed 18  cases  of  the  disease  developing  in  the  first  2l<2  years  of  life,  in 
our  own  patients  or,  in  a  few  instances,  in  those  of  colleagues.  We  col- 
lected also  from  medical  literature,  including  these  cases,  139  reported 
as  occurring  in  the  1st  year,  187  in  the  2d  year,  and  68  in  the  first  half 
of  the  3d  year.  While  undoubtedly  many  of  these  were  instances  of 
errors  of  diagnosis,  there  have  certainly  existed  very  many  more  in  which 
the  disease  has  not  been  recognized,  or,  recognized,  has  not  been  reported. 

In  the  spring  of  1906  there  were  in  the  Infants'  Ward  of  the  Children's 
Hospital,  Philadelphia,  which  contained  but  a  small  number  of  beds, 

1  Amer.  .Journ.  Med.  Sci.,    1837,  XIX,  Feb.  and  XX,  Aug. 

2  Mai.  des  enf.,  3d  Ed.,  615,  III,  373. 

3  N.  Y.  Med.  Rec,  1895,  XLVIII,  803. 

*  Observ.  sur.  la  fievre  typh.  de  I'enf.,  1885. 
6  Amer.  Journ.  Med.  Sci.,  1902,  Nov..  868. 


TYPHOID  FEVER  391 

5  cases  of  typhoid  fever  at  the  same  tune,  in  subjects  not  over  2  years 
of  age.  Writing  in  1912^  I  analyzed  75  cases  occurring  in  the  first  23^^ 
years  of  Hfe,  personally  attended  in  hospital  or  private  practice  or  in 
the  practice  of  colleagues  in  the  Children's  Hospital. 

Typhoid  fever  may  even  be  found  in  the  fetus  and  the  new  born 
(Fetal  and  Congenital  Typhoid  Fever).  In  1898  I  collected  from  med- 
ical literature  10  such  cases^  which  appeared  to  be  beyond  question,  the 
germs  having  been  recovered  from  the  tissues  or  the  blood.  A  few  addi- 
tional instances  have  since  been  collected  (Griffith  and  Ostheimer;^ 
Morse*).  Whether  the  fetus  can  suffer  from  the  disease  in  utero,  recover, 
and  be  born  alive  and  well,  is  not  yet  established.  The  discovery  of 
the  agglutinative  reaction  in  the  blood  of  a  healthy  new-born  infant, 
born  of  a  typhoid  mother  and  not  jQt  suckled  by  her,  would  make 
prenatal  recovery  a  possible  thing,  but  would  not  be  certain  proof  of 
this,  since  the  agglutinating  principle  may  have  passed  to  the  fetus  from 
the  placenta,  without  there  having  been  any  actual  disease  of  the  fetus 
present.     (See  p.  401.) 

The  youngest  reported  instance  of  typhoid  fever  acquired  after  birth 
is  that  by  Gerhardt  in  an  infant  of  3  weeks. ^  I  have  seen  1  case  at  3 
months.^ 

Sex  exerts  practically  no  etiological  influence,  although  hospital  sta- 
tistics generally  give  more  male  cases  than  female.  Previous  good  health 
would  appear  rather  to  favor  than  to  prevent  infection.  So  also  favor- 
able hygienic  conditions  apart  from  the  question  of  the  transmitting 
of  germs  exert  no  protective  power.  Statements  regarding  the  influence 
of  other  diseases  present  seem  to  be  very  contradictory.  In  my  experi- 
ence they  appear  not  to  be  a  factor,  except  that  very  possibly  dietetic 
errors,  producing  an  irritated  condition  of  the  intestinal  canal,  may  read- 
ily predispose.  Typhoid  fever  tends  to  occur  in  epidemics,  which,  however, 
are  more  limited  in  locality  than  in  the  case  of  many  other  infectious  fev- 
ers. In  large  cities  it  is  more  or  less  endemic.  It  is  particularly  where 
the  disease  occurs  in  several  members  of  one  family  that  children  are 
liable  to  be  attacked.  The  individual  susceptibility  seems  less  than  that 
in  many  other  infectious  diseases.  Whether  or  not  the  lesser  frequencj' 
in  infancy  is  due  to  a  lesser  susceptibility  or  to  an  absence  of  equal  expo- 
sure is  uncertain,  but  the  latter  seems  more  probable.  The  fact  that  the 
milk  consumed  is  so  often  subjected  to  a  high  temperature  and  the 
germs  consequently  killed  would  readily  account  for  this. 

Exciting  Cause. — The  exciting  cause  of  typhoid  fever  is  the  bacillus 
trjphosus  of  E})erth,  an  actively  motile  organism  of  the  colon-bacillus  group 
found  widely  spread  throughout  the  tissues  of  the  body  and  in  the  blood, 
bile,  sputum,  stools  and  urine. 

Transmission. — It  is  certain  that  in  the  vast  majority  of  cases  the 
transmission  of  the  germs  is  by  the  feces  or  the  urine.  The  feces, 
however,  do  not  appear  to  be  a  favorable  substance  for  the  actual  growth 
of  the  bacilli,  and  those  found  there  have  entered  with  the  bile,  the  gall- 
bladder being  a  region  where  the  bacilli  may  persist  for  long  periods. 
Whether  the  expired  air  conveys  the  germs  to  any  noteworthy  extent  is 

1  Arch,  of  Pediat.,  1912,  August. 

2  Phila.  Med.  Journ.,  1898,  Oct.  15. 
'  Loc.  cit. 

*  Med.  News,  1903,  LXXXIII,  193. 

^  Handb.  der  Kiiiderkr.,  II,  373. 

6  Phila.  Med.  Journ.,  1898,  II  Oct.  15. 


392  THE  DISEASES  OF  CHILDREN 

doubtful.  Water  used  for  drinking  and  other  purposes  is  the  most 
frequent  carrier,  and  numerous  large  epidemics  have  been  traced  to  this 
source,  while  milk  contaminated  by  germ-containing  water,  or  by  the 
infected  hands  of  milkers,  is  a  common  carrier  in  early  life  unless  it  had 
been  boiled  before  it  was  ingested.  Kober^  analyzed  195  epidemics  of 
typhoid  fever  and  found  that  the  disease  was  transmitted  in  probably 
148  in  this  way.  The  bacilli  may  also  be  transported  from  typhoid  stools 
by  flies  (Vaughn)'  and  possibly  also  from  the  same  source  by  the  wind 
(Pfuhl).3 

In  the  ordinary  sense  of  the  term,  however,  typhoid  fever  is  but  little 
contagious,  and  the  isolation  of  patients  is  not  essential.  Although  hos- 
pital infection  has  repeatedly  occurred  and  the  disease  has  spread  in 
families  from  the  sick  to  the  well,  this  has  not  been  through  mere  prox- 
imity, but  through  lack  of  ordinary  care  in  disinfection.  Unquestionably 
the  soiled  hands  of  a  nurse,  or  garments  or  other  articles  soiled  by  feces 
and  urine,  can  transmit  the  germs  to  the  food  or  other  objects  which  enter 
the  mouths  of  children.  The  acquiring  of  the  disease  in  this  way  occurs 
probably  most  frequently  in  early  life.  Whether  typhoid  fever  may  be 
contracted  through  germs  transmitted  in  the  milk  from  a  mother  suffer- 
ing with  the  disease  is  uncertain,  although  the  passage  of  the  agglutina- 
ting principle  is  well  recognized.     (See  pp.  391;  401.) 

However  transmitted  the  germs  are  probably  always  absorbed  through 
the  digestive  tract  and  rapidly  pass  into  the  blood.  An  exception 
is  seen  in  the  case  of  fetal  typhoid  fever,  where  the  transmission  is  by 
way  of  the  placental  blood.  The  period  of  greatest  infectiousness  appears 
to  be  during  the  2d  and  3d  week  of  the  disease,  or  later  until  healing  of 
the  intestinal  ulcers  has  taken  place,  but  Conradi*  from  a  study  of  600 
cases  of  all  ages  found  the  bacilli  in  the  feces  even  during  the  stage  of 
incubation,  and  believed  that  the  infection  is  often  transmitted  during 
this  period.  The  tenacity  of  life  of  the  germ  both  within  and  without 
the  body  is  often  very  great.  It  may  survive  under  favorable  circum- 
stances for  months,  or  even  for  years,  and  it  is  not  destroyed  by  ordinary 
cold  or  by  drying,  but  is  killed  by  a  temperature  of  60°C.  (140°F.),  by 
disinfectants  and  by  sunlight.  In  a  case  reported  by  Soper"  it  seemed 
probable  that  the  germ  had  continued  present  in  the  intestines  of  an 
individual  during  5  years,  and  cases  of  the  persistence  for  much  longer 
periods  are  on  record.  (Dean,^  29  years;  Bolduan  and  Noble, '^  46  years; 
and  others.)     Such  long  persistence  is,  however,  very  unusual. 

Pathological  Anatomy.^ — ^The  lesions  so  characteristic  of  the  disease 
in  fatal  cases  in  adults  are  notably  altered  in  early  life.  In  fetal 
typhoid  fever  there  is  an  entire  absence  of  intestinal  ulceration,  perhaps 
the  natural  result  of  the  placental  mode  of  entrance  of  the  germs.  In 
the  majority  of  congenital  cases,  too,  intestinal  lesions  have  not  been 
reported,  and  this  is  occasionally  true  of  older  subjects.  After  these 
periods  the  lesions  vary  somewhat  with  the  age  of  the  patients.  In  the 
first  2  years  of  life  the  process  is  more  hyperplastic  than  destructive,  and 
the  solitary  and  agminated  glands  are  swollen,  projecting,  and  of  a  pink- 

1  Amer.  Journ.  Med.  Sol.,  1901,  May. 

2  Amer.  Journ.  Med.  Sci.,  1899,  CXVIII,  10. 

3  Zeitschr.  f.  Hyg.,  1893,  XIV,  1. 

*  Deut.  med.  Woch.,  1907,  XXXIII,  1684. 

5  Journ.  Amer.  Med.  A.ssoc.,  1907,  XLVIII,  2019. 

6  Brit.  Med.  Journ.,  1908,  I,  562. 

'  Journ.  Amer.  Med.  Assoc.,  1912,  LVIII,  7. 


TYPHOID  FEVER 


393 


ish  color.  Slight  and  generall}^  superficial  ulceration  may  be  present, 
and  in  some  cases  there  is  no  intestinal  involvement  whatever.  The 
swelling  of  the  mesenteric  glands  is  usually  very  pronounced  and  the 
spleen  is  always  acutely  enlarged  and  soft;  and  these  two  conditions  are 
suggestive;  but  there  is  nothing  in  the  post-mortem  findings  in  infancy 
which  is  positively  diagnostic  of  typhoid  fever. 

In  earlj^  childhood,  between  the  ages  of  2  and  6  years,  the  lesions  are 
very  similar  to  those  just  described,  except  that  the  intestinal  ulceration 
is  somewhat  more  marked.  It  is  still,  however,  generally  superficial 
and  the  process  is  predominatingly  hyperplastic.  There  are,  however, 
many  exceptions  to  this  rule,  and  very  extensive  ulceration  may  occur 
even  at  6  years  (Fig.  92.) 


Fici.  92. — Ulcehati.jx  i.\  'I'vphoid  Fk\  1. 1; 
Child  of  6  years.     Autopsy  showed  an  unusual  degree  of  intestinal  lesions  for  this 
time  of  life. 


In  later  childliood  intestinal  ulceration  becomes  much  more  frcciuent 
and  decided,  although  in  most  cases  less  marked  than  in  adult  liio.  It 
is  only  as  the  age  of  pubert}'  is  approached  that  the  lesions  are  practically 
the  same  as  in  the  adult. 

Typhoid  bacilli  are  found  in  the  various  secretions  and  excretions,  in 
different  organs,  the  rose  spots  and  the  blood.  They  may  be  discov- 
ered in  the  stools  often  before  the  serum  reaction  can  be  obtained.  The 
tissue-degenerations  occurring  in  adult  cases  are  absent  or  less  marked 
in  early  life. 


394  THE  DISEASES  OF  CHILDREN 

Symptoms. — The  period  of  incubation  is  variable  and  difficult  of 
precise  determination.  It  may  in  general  be  placed  at  from  1  to  2  weeks. 
Languor,  loss  of  appetite,  and  allied  symptoms  characterize  it  in  the 
majority  of  cases.  The  actual  beginning  of  invasion  as  marked  by  the 
development  of  fever  which  continues  in  average  cases  about  a  week 
before  the  second  or  eruptive  stage  is  ushered  in  by  the  appearance  of  the 
roseola. 

The  symptoms  of  the  attack  vary  according  as  the  disease  occurs  in 
the  new  born,  in  infancy  after  this  period,  in  early  childhood  (2  to  6  years), 
or  in  later  childhood.  These  divisions  are  to  be  viewed  merely  as  an 
artificial  classification,  since  a  great  many  exceptions  exist,  and  subjects 
in  one  age-class  may  exhibit  the  symptoms  of  those  pertaining  to  another. 
The  peculiarities  of  the  average  case  as  observed  in  the  latter  part  of 
early  childhood  and  the  first  portion  of  later  childhood  may  be  reviewed 
as  those  characteristic  of  the  general  type  for  early  life. 

Ordinary  Course. — The  principle  symptoms  distinguishing  the 
disease  in  earl}^  life  are:  (1)  The  indefinite  and  uncharacteristic  onset; 
(2)  the  shorter  duration  and  greater  mildness  of  the  attack;  (3)  the 
disposition  for  nervous  symptoms  to  over-balance  intestinal  ones.  This 
does  not  mean  at  all  that  the  nervous  symptoms  are  actually  more 
marked  than  in  adult  life. 

In  many  cases  the  onset  is  very  abrupt,  particularly  in  young  children, 
the  disease  becoming  thoroughly  developed  in  the  course  of  a  few  days. 
Vomiting  may  be  one  of  the  first  symptoms  in  such  cases.  The  disease 
is  occasionally  ushered  in  by  convulsions,  or  may  begin  violently  with 
the  manifestations  of  meningitis  so  well-marked  that  the  true  nature  of  the 
malady  is  discovered  only  later.  In  the  majority  of  cases,  however,  the 
onset  is  peculiarly  insidious  and  even  long-continued,  with  symptoms  so 
little  pronounced  that  the  roseola  and  enlarged  spleen  may,  perhaps,  be 
found  upon  the  first  examination.  The  child  has  been  walking  about 
with  some  degree  of  malaise,  loss  of  appetite,  slight  headache  and  thirst, 
and  with  fever  which  has  possibly  not  been  recognized  by  the  relatives. 
It  is  then  difficult  to  determine  just  when  the  attack  commenced.  In  other 
cases  the  initial  stage  is  much  shorter,  the  fever  lasting  only  2  or  3  days 
before  the  typhoid  roseola  appears. 

When  the  disease  has  reached  the  second,  or  eruptive  stage  there  is 
generally  an  absence  of  the  severe  nervous  manifestations  which  consti- 
tute the  typhoid  state  as  seen  in  adult  life;  apathy  and  slight  nocturnal 
delirium  being  the  symptoms  oftenest  seen.  The  whole  course  of  the 
attack  is  decidedly  curtailed,  especially  the  stage  of  decline.  An  average 
duration  of  the  attack  may  be  placed  at  from  14  to  20  days. 

To  this  general  description  there  arc,  of  course,  very  numerous  ex- 
ceptions, and  cases  may  vary  in  duration  from  that  of  the  abortive  type 
to  that  greatly  prolonged;  and  in  severity  from  the  mildest  to  the  most 
pronounced. 

The  symptoms  can  best  be  studied  individually.  Of  the  gastro- 
intestinal symptoms,  vomiting  is  a  frequent  initial  manifestation,  and 
even  later  is  more  common  than  in  adults,  and  sometimes  almost  or  quite 
uncontrollable.  I  have  seen  this  the  direct  cause  of  death.  Sore  throat 
is  an  occasional  initial  symptom  and  the  tonsils  may  be  red  and  swol- 
len. The  appetite  is  diminished  and  thirst  is  present.  The  tongue  is 
generally  coated,  and  often  exhibits  the  red  triangle  at  the  tip  and  the 
red  edges  frequently  described  as  characteristic  of  the  disease.  Dryness 
develops,  as  a  rule,  only  in  the  severer  cases  in  older  children. 


TYPHOID  FEVER 


395 


The  condition  of  the  bowels  is  variable.  Constipation  and  diarrhea 
are  about  equally  frequent,  the  former  perhaps  preponderating.  Yet  this 
depends  upon  the  epidemic  and  there  have  been  years  in  which  nearly 
all  the  cases  under  my  care  had  diarrhea,  although  generally  not  severe. 
The  stools  may  show  the  typical  pea-soup  appearance.  Involuntary 
evacuation  occurs  only  exceptionally  and  in  the  severest  cases. 

The  abdomen  is  generally  only  moderately  distended  and  may  be 
slightly  tender  in  the  right  iliac  fossa,  but  great  distention  and  decided 
tenderness  are  much  less  often  seen  than  in  adult  life. 

Enlargement  of  the  spleen  is  always  present,  although  not  always  de- 
monstrable. It  can  be  detected  in  probably  80  to  90  per  cent,  of  all 
cases  in  children.  Russow^  observed  it  in  85  per  cent,  of  1034  cases  in 
children.     It  is  discoverable  at  about  the  same  time  as  the  eruption.     As 


Fig.  9.J. — Tvi'huid  Fever  with  ax  L'.\u.slal  Degree  of  Develui'.\ie.nt  uk  the  Ehl  ptiox. 
Minnie  S.,  admitted  to  the  Children's  Hospital  of  Philadelphia  Feb.  22,  aged  5  years. 
Illness  began  5  days  before.  Spots  on  abdomen  observed  the  day  before  admission.  The 
day  after  admission  the  spots  were  very  numerous,  and  were  seen  also  on  the  face.  Spleen 
palpable.     Recovery. 


long  as  it  persists  the  typhoid  process  cannot  be  considered  completed. 
Lymphatic  glandular  enlargement  is  not  infrequent  but  is  generally  slight. 
The  typhoid  roseola  is  sometimes  stated  to  be  less  often  present  or  less 
well  developed  in  children.  In  my  own  experience  this  is  not  the  case,  and 
in  671  cases  reported  by  Morse-  the  eruption  was  observed  in  GO  per 
cent.  Henoch''  found  it  absent  only  19  times  in  381  cases.  In  average 
cases  it  is  discoverable  about  the  end  of  the  1st  week.  As  in  the  adult, 
the  spots  appear  in  successive  crops,  each  lasting  about  3  days.  Excep- 
tionally the  eruption  is  well  marked  over  the  whole  body,  involving  even 
the  face,  and  sometimes  suggesting  closely  the  early  appearance  of  the 
rash  of  measles  (Fig.  93).  The  spots  continue  to  develop  as  long  as  the 
infection  is  active  in  the  .system.  Sudamina  are  conunon,  especially 
in  older  children.  A  branny  dcs(iuamation  during  convalescence  has 
been  described  as  especially  liable  to  occur  in  children.  1  iuivc  noted 
it  freciuently. 

1  Padiatrija,  1911,  Xo.  .3.     Rcf.  Monatsschr.f.  Kinderh.,iRefcrat.,  11)12,  111,  224. 

2  Bost.  Med.  und  SurK.  .Journ..  1896,  CXXXIV  205. 
'  Kinderkrankheiten,  1895,  773. 


396 


THE  DISEASES  OF  CHILDREN 


The  temperature  often  runs  a  very  irregular  course.  When  typical  it 
resembles  that  of  adult  cases  except  for  the  shorter  duration  and  the 
frequent  absence  of  the  terminal  remittent  character  (Fig.  94).  In  the 
initial  stage  it  shows  an  evening  rise  and  morning  fall,  with  the  gradual 
step-like  ascent  lasting  until  about  the  end  of  the  1st  week.  In 
very  many  cases,  however,  this  stage  is  shortened  greatly,  and  the  fever 
rapidly  rises  to  its  maximum  without  the  step-like  character.  In  the 
second  stage,  that  of  the  "acme,"  fastigium,"  or  "eruptive  period,"  the 
temperature    remains    continuously  high,   from   103°  to  over   104°F., 


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Evelyn  P.,  aged  11  years.  Nov.  26,  chilly  2  days  ago,  been  feeling  tired,  slight  sore 
throat;  Nov.  28,  spleen  enlarged  to  palpation,  appetite  poor;  Nov.  30,  general  condition 
excellent,  slight  diarrhea,  leucocytes  10,400;  Dec.  2,  rose  spots  found,  Widal  reaction  nega- 
tive; Dec.  6,  mind  entirely  clear,  slight  diarrhea,  Widal  negative;  Dec.  9,  been  no  nervous 
symptoms  except  moderate  apathy;  Dec.  15,  convalescent,  appetite  still  poor. 

(39.4°  to  40°C.)  with  but  little  variation  between  morning  and  evening 
elevations.  The  high  temperature,  however,  is  generally  much  better 
tolerated  than  in  adult  life.  In  one  instance  a  girl  10  years  showed  a 
temperature  of  107°F.  (41.7°C.)  without  the  slightest  sign  of  discomfort 
or  of  nervous  symptoms.  The  temperature  of  the  third  stage,  or  stage  of 
dechne,  is  of  much  shorter  duration  than  in  adults  (Fig.  95).  Accord- 
ing to  Morse's  statistics^  the  prolonged  remittent  form  is  absent  in  about 
}-i  of  the  cases.  This  absence  doubtless  depends  on  the  lesser  degree 
of  intestinal  involvement.  The  final  fall  is  commonly  much  more  rapid 
than  in  adults,  and  is  often  almost  critical  (Fig.  96). 

Although  the  average  duration  of  the  fever  is  from  2  to  3  weeks,  yet 
numerous  exceptions  are   observed.     Sometimes  it  lasts  little   over  a 

1  Bost.  Med.  and  Surg.  Jour.,  1896,  CXXXIV,  205. 


TYPHOID  FEVER 


397 


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Theresa  F.,  aged  7  years.     Came  home  from  school  with  headache  on  Feb.  19;  first 
seen  Feb.  21;  had  not  been  in  bed.     During  attack  exhibited  loss  of  appetite,  enlarged 
spleen,  very  little  apathy,  Widal  reaction.     Was  bright   all  the  time.     A  few  spots  first 
found  during  a  relapse. 


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George  C,  aged  7I-2  years.     Sudden  onset  with  convulsion.     During  attack  cxhibite^l 
roseola,  splenic  enlargement,  moderate  diarrhea,  good  general  condition.     Temperature  fell 
critically  on  the  14th  day  of  the  attack. 


398 


THE  DISEASES  OF  CHILDREN 


week,  while  in  other  cases  it  continues  high  with  httle  change  for  3  or  4 
weeks  or  more.  Before  complete  defervescence  takes  place  there  is  shown 
a  tendency  for  the  temperature  to  become  elevated  from  insignificant  or 
undiscoverable  causes  (Fig.  97).  This  may  in  some  cases  j-esult  in 
an  unusual  prolongation  of  an  irregular  pyrexia.  In  other  cases  this  is 
probably  the  result  of  an  unusual  persistence  of  the  infectious  process. 
In  children  apparently  otherwise  convalescent  I  have  seen  fever  continue 
for  6  or  7  weeks  (Fig.  98)  and  in  one  instance  for  over  12  weeks.  How 
irregular  and  deceptive  the  course  of  the  temperature  may  be  at  times 
is  illustrated  in  the  accompanying  chart  (Fig.  99)  of  a  case  in  which  only 


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Fig.  97. — Recrudescence  in  Typhoid  Fever. 
Chas.  L.,  aged  5  years.     Recovering  from  relapse. 
Fig.  98. — Typhoid  Fever,  Protracted  Case,  No  Complications. 
Rose  B.,  aged  8  years.     Disease  ran  ordinary  course,  rather  mild,  splenic  enlargement 
and  rose  spots.     Then  developed  irregular  fever  without  other  symptoms  or  discoverable 
cause.     This  lasted  until  the  46th  day. 


the  blood-culture  made  the  suspected  diagnosis  finally  certain.  The 
chart  does  not  represent  the  temperature-record  at  the  same  time  daily, 
but  rather  the  maximum  and  minimum  for  each  day,  there  having 
been  an  entire  absence  of  regularity  in  the  hours  of  these  occurrences. 
The  chief  characteristic  of  the  blood  in  typhoid  fever  is  the  absence  of 
leucocytosis.  The  normal  number  of  leucocytes  belonging  to  the  differ- 
ent ages  of  children  (p.  59)  must  be  taken  into  consideration  in  this  con- 
nection, as  also  the  very  great  ease  with  which  many  secondary  conditions 
may  produce  leucocytosis  in  children  with  typhoid  fever.  An  increase 
in  the  number  of  leucocytes  is  consequently  not  positive  evidence  that 


TYPHOID  FEVER 


399 


typhoid  fever  is  absent.  A  low  leucocyte-count  is  of  much  more  value  in 
forming  a  diagnosis.  Allowing  for  the  influence  of  age,  the  differential 
count  gives  results  identical  with  those  seen  in  adults;  there  being  a  de- 
crease in  the  number  of  neutrophiles  and  an  increase  of  the  mononuclear 
cells,  especially  the  lymphocytes.  The  eosinophiles  are  diminished. 
The  percentage  of  hemoglobin  and  of  red  cells  is  decidedly  reduced  as 
the  disease  advances.  The  typhoid  bacilli  may  often  be  found  in  the 
blood  before  the  Widal  reaction  can  be  obtained.     After  convalescence 


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Christopher  S.,  aged  8  years.  Patient  in  the  C^hildren's  Hospital,  Pliila.  Jan.  7,  intense 
headache,  leucocytes  at  first  14,200,  tache,  rigidity  of  neck,  Kernig's  sign,  ankle-clonus, 
profuse  sweating  and  chills,  suspected  of  being  malaria,  cerebral  abscess,  meningitis,  or 
sepsis,  lumbar  puncture  negative,  no  plasmodia;  Jan.  14,  blood-culture  positive  for  typhoid 
bacilli,  rose  spots,  positive  agglutinative  reaction,  leucocj'tes  now  9800. 


from  severe  attacks  the  hemoglobin  especially  shows  a  percentage-reduc- 
tion. The  blood-serum  added  to  a  fresh  culture  of  tyiihoid  l)acilli  causes 
a  cessation  of  the  movements  and  a  clumping  of  the  germs  ("serum," 
"agglutinative,''  or  "Widal"  reaction).  It  occurs  in  al)<)ut  95  per  cent, 
of  cases.  It  was  present  in  94  per  cent,  of  ()(>  of  my  cases  in  the  first  2'  2 
years  of  life.  It  is  usually  not  obtainable  before  the  5th  or  (Uh  day  of  the 
attack,  or  sometimes  not  until  this  is  well  advanced  or  the  jviticnt  even 
convalescing.  It  may  even  be  absent  during  the  entire  cour.>^e  of  the 
primary  attack  and  develop  during  a  relapse.  It  may  continue  for 
months  after  the  disease  is  over. 

The  pulse,  as  in  adults,  is  not  infrequently  slower  than  the  elevation  of 
temperature  would   call  for,    and  has  a  decided  tendency  to  dierotism; 


400  THE  DISEASES  OF  CHILDREN 

generally,  however,  only  in  older  children.  Not  infrequently  it  is  quite 
irregular  and  peculiarly  slow  during  convalescence.  In  bad  cases  it  may 
be  irregular  or  unusually  rapid  during  the  course  of  the  disease.  The 
arterial  tension  is  low.  The  cardiosphygmographic  studies  made  by 
Schlieps^  on  100  children  with  typhoid  fever  showed  that  the  commonly 
observed  arrhythmias  are  dependent  upon  sinus-irregularities  and  do  not 
affect  the  prognosis.  In  severe  attacks  a  dusky-red  flushing  of  the  cheeks 
sometimes  indicates  the  vasomotor  disturbance  present. 

Of  symptoms  connected  with  respiration  cough  is  common  yet  seldom 
troublesome,  and  coarse  rales  are  often  heard  in  the  chest.  Epistaxis 
is  probably  not  as  common  an  initial  sjmiptom  as  in  adults.  Its  occur- 
rence in  40.9  per  cent,  of  550  cases  as  reported  by  Adams'  would  appear 
to  be  unusual.  Except  in  the  mild  cases  emaciation  is  commonly  very 
decided  and  is  sometimes  extreme.  Nervous  symptoms,  although  more 
marked  than  intestinal,  are,  as  stated  generally  less  severe  than  in  adult 
life.  Headache  is  quite  common,  especially  at  the  outset,  but  it  is  not 
often  intense  or  persistent.  In  severe  cases  there  may  be  much  pain  in 
the  limbs,  or  the  back  or  joints.  I  have  known  stiffness  of  the  muscles 
of  the  neck  to  occur,  without  the  mental  symptoms  which  would  sug- 
gest meningitis.  The  abdominal  reflex  is  diminished.  Many  children 
remain  in  the  best  of  spirits  throughout  the  attack  and  do  not  feel  or 
appear  particularly  ill;  while  others  are  usually  irritable,  especially  if  dis- 
turbed. Oftenest,  however,  the  principal  and  the  most  characteristic 
nervous  symptom  is  a  decided  apathy,  with  a  tendency  to  be  quiet 
and  to  sleep,  which  is  increased  when  the  temperature  rises.  Prostra- 
tion is  seldom  as  great  as  in  adult  cases,  except  after  unusually  severe 
attacks  or  in  patients  in  whom  some  debilitating  cause,  such  as  severe 
diarrhea,  has  been  present.  Delirium  is  generally  absent  or  slight,  oc- 
curring only  at  night,  but  in  severe  cases  may  become  very  pronounced. 
Convulsions  sometimes  usher  in  the  attack  (Fig.  96)  even  in  cases  which 
are  not  later  severe.  Coma,  stupor,  coma  vigil  and  subsultus  are  rarely 
seen  except  in  older  children.  A  condition  strongly  suggesting  menin- 
gitis is  sometimes  observed  during  much  of  the  attack.  This  is  not 
frequent,  although  probably  oftener  seen  than  in  adults  (^Fig.  106). 

The  urine  exhibits  a  decided  diazo  reaction.  Febrile  albuminuria  may 
be  present  if  the  temperature  is  high,  but  evidences  of  nephritis  are 
not  as  common  as  in  adults.     Acetone  is  occasionally  found. 

Variations  in  Type. — Different  types  of  typhoid  fever  seen  in  early 
life  may  be  described.  The  classification  may  be  made  either  (A) 
according  to  the  age  of  the  patient,  or  (B)  according  to  the  characteristics 
of  the  attack  in  general. 

(A)  Based  upon  age  the  following  types  may  be  mentioned: 

1.  Fetal  and  Congenital  Typhoid  Fever. — The  only  distinction  be- 
tween these  two  varieties  is  that  in  the  latter  the  child  is  born  alive  and 
consequently  exhibits  symptoms. 

The  majority  of  pregnant  women  suffering  from  typhoid  fever  abort. 
The  collected  statistics  of  Etienne^  show  this  occurrence  in  70  per  cent, 
of  pregnant  women  with  the  disease.  Nothing  in  the  superficial  appear- 
ance of  the  body  of  the  infected  fetus  indicates  the  nature  of  the  disorder, 
but  the  germs  may  be  recovered  from  the  blood  and  the  organs.     In 

1  Jahrb.  f.  Kinderh.,  1911,  LXXIV,  386. 
-  Amcr.  Journ.  Med.  Sci.,  1910,  May. 
3  Gaz.  hebdom.,  1896,  XLIII,  184. 


TYPHOID  FEVER 


401 


the  congenital  cases  the  infant  is  born  aUve,  sometimes  prematurely  and 
sometimes  at  term.  Life  may  continue  only  a  few  minutes,  the  cause 
of  death  not  being  apparent.  In  others  the  disease  may  last  several 
days,  or  even  2  weeks  or  longer.  The  symptoms  are  usually  [entirely 
uncharacteristic.  Fever  is  generally  present;  and  convulsions,  jaundice 
diarrhea,  constipation,  tympanities,  roseola,  enlarged  spleen,  cough, 
vomiting,  intestinal  hemorrhage  and  purpura  have  been  reported.  Death 
almost  always  occurs.  As  already  pointed  out  the  discovery  of  the 
Widal  reaction  in  these  cases  cannot  be  looked  upon  as  diagnostic,  since 
it  may  be  found  in  apparently  healthy  children  born  of  typhoid  mothers, 
the  agglutinating  principle  having  entered  either  by  way  of  the  placental 
circulation  or  through  the  milk.     (See  p.  391.)   , 


Fig.  100. — Ixfaxtile  Typhoid  Fever. 
William  H.,  aged  3  months.  Child  restless,  with  slight  cough,  abdominal  distention, 
moderate  diarrhea  with  greenish  stools,  increasing  weakness,  stupor  and  loss  of  appetite. 
Death  on  Feb.  13.  Diagnosis  supposed  to  be  ileocolitis.  Autopsy  showed  spleen  soft  and 
much  enlarged,  Peyer's  patches  and  mesenteric  glands  hyperplastic,  Widal  reaction  in 
heart's  blood.     Case  illustrates  severe  course  with  uncharacteristic  symptoms. 


2.  Infantile  'Typhoid  Fever. — Under  this  heading  may  be  includtnl 
cases  in  which  the  affection  was  acquired  after  birth  and  during  the 
first  2  years  of  life.  The  disease  in  this  period,  and  especially  in  the 
1st  year,  is  often  marked  by  the  absence  of  most  of  the  characteristic 
symptoms,  the  diagnosis  being  impossible  until  the  typhoid  eruption  or 
the  agglutinative  reaction  is  discovered.  The  temperature  is  generally 
high  and  very  irregular  in  type,  and  is  usually  attributed  to  some  of  the 
many  other  causes  of  fever  in  early  life.  Very  often  the  disease  is  sup- 
posed to  be  an  ileocolitis  of  moderate  severity,  since  diarrhea  is  a  frequent 
symptom  common  to  both  (Figs.  100,  107,  100).  Diarrhea,  tympanites 
and  vomiting  are  rather  more  frequent  at  this  time  of  UlV  than  later. 

26 


402 


THE  DISEASES  OF  CHILDREN 


Bronchitis  is  of  common  occm'rence;  epistaxis  uncommon.  The  patient 
is  often  prostrated,  and  may  seem  more  ill  than  the  symptoms  rationally 
explain.  The  pulse  is  rapid  and  nervous  symptoms  may  be  marked, 
fretfulness  and  restlessness  being  more  frequently  seen  than  apathy. 
As  in  fetal  typhoid  the  disease  often  takes  the  form  of  a  blood-infection 
without  special  local  symptoms  (Fig.  107). 

3.  Typhoid  Fever  in  Early  Childhood. — At  this  period,  from  the  age 
of  2  up  to  that  of  6  years,  the  attack  is  usually  of  a  more  benign  type  than 
at  any  other  time  of  life.  It  is  now  that  the  characteristics  already 
described  as  those  of  the  disease  in  early  life  are  most  prone  to  show 
themselves.     Diarrhea  is  less  common  than  either  in  infancy  or  in  later 


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Fig.   101. — Typhoid  Fever  in  Early  Childhood,  Severe  Case. 
Sadie  T.,  aged  3  years.     Rapid  onset  with  fever  and  prostration  and  loss  of  appetite. 
During  attack  suffered  from  slight  diarrhea,  numerous  rales  in  chest,  occasionally  dyspnea, 
apathy,    sopor,    sometimes    great    irritability,    occasional    vomiting,    severe    abdominal 
distention,  cyanosis.     Death  on  the  14th  day  of  the  disease. 

childhood  and  is  seldom  troublesome.  The  temperature  is  more  sugges- 
tive of  typhoid  fever  than  in  infancy,  but  that  of  the  third  stage  is  gener- 
ally much  abbreviated  and  not  of  a  remittent  type.  The  course  is  short. 
Nervous  symptoms  are  nearly  always  mild  except  in  the  cases  with  a 
meningitic  onset.  Complications  are  not  as  frequent  as  later.  To  this 
description  there  are  of  course  numerous  exceptions,  and  the  attack 
may  be  very  severe  (Fig.  101). 

4.  Typhoid  Fever  in  Later  Childhood.^ — This  lype  is  distinctly 
more  like  that  seen  in  adults,  and  the  nearer  the  child  is  to  puberty, 
the  closer  is  the  resemblance  liable  to  be.  This  is  especially  true  after 
the  age  of  10  years  (Fig.  102).  Diarrhea  may  now  be  troublesome,  and 
hemorrhage  and  perforation  are  more  liable  to  occur  than  earlier,  all  this 
depending  upon  the  greater  likelihood  of  intestinal  ulceration  at  this  time 


TYPHOID  FEVER 


403 


of  life.  The  symptoms  of  the  typhoid  state  are  more  prone  to  develop, 
but  only  in  severe  cases  to  any  great  degree.  The  course  is  apt  to  be 
longer  than  in  early  childhood,  and  the  fever  of  the  third  stage  is  oftener 
of  the  remittent  type. 

{B)  Based  also  upon  the  symptoms  as  a  whole,  regardless  of  age, 
the  following  varieties  may  be  mentioned:  \ 

1.  Abortive  Form. — In  this  form  all  the  characteristic  early  symp- 
toms may  be  present  in  a  mild  (Fig.  103)  or  in  the  ordinary  or  a  severe 


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Fig.   102. — Typhoid    Fever,    Later    Childhood.    Severe    Case    of    Adclt    Type    of 

Disease. 
Thelma  M.,  aged  11    years.     Suffered  from  headache,  stuporous  most  of  time,  mut- 
tering   delirium,    carphologia,    occasionally   actively   delirious,    coated    tongue,    dry   lips, 
troublesome  abdominal  distention. 


form  (Fig.  104),  but  the  course  is  greatly  abbreviated,  lasting  only  8 
to  10  days.  These  cases  are  not  infrequent,  being  much  more  common 
than  in  adults. 

2.  Mild  Form. — This  variety  may  be  abortive  also,  as  regards  its 
duration,  but  the  term  is  much  better  applied  to  those  cases  in  which  all 
the  symptoms  are  peculiarly  mild  although  the  attack  is  not  unusually 
curtailed.  It  is  the  form  very  commonly  seen  in  early  childhood.  There 
is  no  diarrhea,  loss  of  appetite,  or  prostration;  and,  in  fact,  practically 
no  suljjective  symptoms  except  possibly  slight  heatlache  and  a  trifling 
degree  of  apathy.  Only  the  continuctl  fever  of  moderate  degree,  the 
Widal  reaction,  and  possibly  the  discovery  of  rose  spots  and  enlargement 
of  the  spleen  indicate  the  presence  of  the  disease.  Even  the  temperature 
may  in  occasional  cases  scarcely  exceed  100°F.  (37.8°C\)  {Afebrile 
form).  Sometimes  only  the  occurrence  of  the  case  in  a  family  outbreak 
makes  the  diagnosis  clear  (Fig.  105). 


404 


THE  DISEASES  OF  CHILDREN 


3.  Nervous  Form. — This  occurs  not  infrequently,  and  is  often  the 
cause  of  great  difficulty  in  diagnosis.  The  disease  may  begin  abruptly 
as  a  pseudonieningitis,  with  repeated  convulsions  continuing  several 
days;  or  there  may  be  unconsciousness,  grinding  of  the  teeth,  intense 
restlessness,  rigidity  of  the  neck,  and  possibly  an  unusually  active  de- 
lirium. These  early  symptoms  may  soon  give  place  to  the  more  usual 
ones  of  the  disease;  but  sometimes,  particularly  in  older  children,  severe 
nervous  symptoms  mav  not  develop  until  later  (Meningitic  typhoid) 
(Fig.  106). 


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Fig.    103. — Abortive    Typhoid    Fever,    Course    Short    and    Symptoms    Mild    From 

Beginning. 
Thelma  M.,  aged  11  years.  Onset  sudden.  Symptoms  consisted  solely  of  slight 
weakness  and  diffused  aching,  fever,  splenic  enlargement.  Fever  ceased  on  9th  day  and 
child  out  of  bed  on  11th  day  of  disease.  Case  supposed  to  be  influenza  until  a  posi- 
tive Widal  reaction  and  later  a  very  severe  relapse  (Fig.  109)  showed  the  nature  of  the 
original  attack. 

Fig.   104. — Abortive  Typhoid  Fever,  Severe  Initial  Symptoms. 
Annie  A.,  aged  7^  years.     Symptoms  of  invasion  consisted  of  fever,  very  frequent 
vomiting,  diarrhea.     Then  improved,  felt  perfectly  well  and  was  bright,  no  apathy,  vom- 
iting and  diarrhea  ceased.     Enlargement  of  spleen  and  roseola  (?)  present.     Widal  reac- 
tion positive.     No  fever  after  10th  day  of  disease. 

Complications  and  Sequels. — Complications  and  sequels  are  not 
common  in  average  cases  in  children.  Those  of  the  respiratory  tract  are 
perhaps  most  frequent.  Bronchitis  is  common,  especially  in  the  severer 
cases  of  the  disease.  Pneumonia  occurs,  although  perhaps  less  often 
than  in  adults.  Severe  laryngitis  is  an  occasional  complication.  I  have 
known  a  child  to  be  aphonic  for  5  or  6  weeks.  In  rare  instances  ulcera- 
tion with  stenosis  may  occur  and  intubation  or  tracheotomy  be  required. 
In  1  instance  a  tracheotomy  tube  was  still  being  worn  after  3  years. 


TYPHOID  FEVER 


405 


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Daniel  B.,  aged  12  years.     At  no  time  any  suggestive  symptoms  whatever  complained 
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Fig.  106. — Nervous  Form  op  Typhoid  Fever.  (Meninoitic  Typhoid.) 
John  S.,faged  10  years.  Sudden  onset  with  nosebleed  and  severe  headache.  Wildly 
delirious  by  ne.xt  day,  with  headache  and  vomiting.  Condition  continued  and  on  6th  day 
of  disea8ei,was  uncf)nscious,  delirious,  lying  on  side  in  gun-iiammer  position,  well-marked 
abdominal  tache.  ]iy  8th  day  of  disease  all  nervous  symptoms  had  greatly  improved  and 
the  ordinary  appearance  of  typhoid  fover  was  present. 


406 


THE  DISEASES  OF  CHILDREN 


Some  of  the  cases  of  laryngeal  involvement  depend  upon  a  laryngeal 
perichondritis.  I  have  observed  this  in  a  few  instances.  Pleurisy  is 
unusual.  Abscess  and  gangrene  of  the  lung  have  both  been  reported, 
and  hypostatic  congestion  may  occur  in  severe  cases.  Disorders  of  the 
circulatory  apparatus  are  for  the  most  part  infrequent.  Pericarditis 
and  endocarditis  are  rare,  venous  or  arterial  thrombosis  very  exceptional. 
More  or  less  anemia  is  a  natural  sequel  in  severe  cases.  A  hemorrhagic 
tendency  with  the  production  of  purpuric  eruptions,  bleeding  of  the  gums 
andjother  evidences  of  the  hemorrhagic  diathesis,  is  very  uncommon  at 
any^time  of  life  {Hemorrhagic  typhoid) .     Epistaxis  may  be  so  severe  thatit 


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Fig.  107. — Typhoid  Fever  with  Fatal  Intestinal  Hemorrhage. 
Martin  D.,  aged  5  months.  Case  shows  short  duration  of  1st  and  3d  stages  as  well 
as  of  the  attack  as  a  whole.  Case  supposed  at  first  probably  to  be  pneumonia,  although 
there  were  no  positive  symptoms  of  any  sort.  Chart  shows  temperature  from  the  day  of 
onset.  Child  suffered  from  restlessness,  crying,  loss  of  appetite,  diarrhea,  vomiting, 
later  rose  spots  and  enlarged  spleen.  Improved  rapidly  then  developed  intestinal  hemor- 
rhage with  return  of  vomiting,  abdominal  pain  and  tenderness,  feeble  circulation,  death. 
Autopsy.  Later  found  that  the  mother  also  was  in  the  Philadelphia  Hospital  with  typhoid 
fever. 


may  be  ranked  as  a  complication.  I  have  seen  it  the  direct  cause  of  death. 
Disturbances  of  the  digestive  system  are  important.  Parotitis  is  only 
occasionally  seen,  but  generally  proceeds  to  suppuration  (p.  668,  Fig.  233). 
Severe  aphthous  stomatitis  is  sometimes  observed,  or  ulcerative  stoma- 
titis going  on  to  necrosis  of  a  small  portion  of  the  bone  with  loss  of  teeth. 
Pseudo-membranous  tonsillitis  occasionally  occurs.  Noma,  although 
uncommon,  is  more  liable  to  develop  after  typhoid  fever  than  after  any 
other  disease  except  measles.  Severe  diarrhea  is  not  infrequent  in  later 
childhood.  Fecal  impaction  is  an  unusual  complicatibn,  of  which  I 
have  seen  but  1  instance.  Intestinal  hemorrhage  is  rare  as  compared 
with  adult  life,  and  is  met  with  almost  only  in  children  of  10  years  or 


TYPHOID  FEVER 


407 


older.  Only  9  cases;  i.e.  1.6  per  cent,  of  553  cases  of  typhoid  fever  in  chil- 
dren collected  by  Morse,  ^  suffered  from  this  symptom.  I  have,  however, 
observed  it  in  many  more  cases  than  this,  in  1  instance  in  an  infant  of 
5  months  (Fig.  107).  Costinesco^  reported  it  22  times  in  762  cases  of  ty- 
phoid fever  in  children.  It  has  been  witnessed  in  some  of  the  congenital 
cases,  but  is  then  rather  a  manifestation  of  a  general  hemorrhagic  state 
dependent  upon  the  septic  condition  of  the  blood.  Intestinal  perfora- 
tion is  another  unusual  complication  in  early  life.     Henoch^  saw  it  but 


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Fig.  108. — Typhoid  Fever  with  Intestin.\l  Perfor.\tion,  Illustrating  Absence  of 
Char.\cteristic  Sympto.ms  of  Perforation  as  Often  Seen. 
Mary  B.,  aged  4  years.  Admitted  to  the  Children's  Hospital  Mar.  8.  Said  to  have 
had  slight  symptoms  of  typhoid  fever  for  10  days.  Attack  ran  a  mild  course,  although 
■with  considerable  abdominal  distention.  Vomited  twice  in  the  morning  of  the  18th  and 
twice  in  the  afternoon.  Had  occasional  slight  abdominal  pain  at  first,  no  distention  or 
tenderness  at  any  time.  Sat  up  in  bed  through  the  morning  and  did  not  look  ill.  In 
the  afternoon  looked  more  ill  and  temperature  had  risen  to  10.5.0°  F.  by  G  p.  m.  Strength 
now  failed  rapidly,  but  entirely  without  abdominal  symptoms.  Died  G  a.  m.  on  the  19th. 
Autopsy  showed  perforation. 

once  in  381  cases,  Morse*  not  at  all  in  284  cases,  Rennert*  4  times  in 
471  cases,  and  Schulz^  but  8  times  in  children.  It  is,  however,  not  so 
rare  as  often  supposed.  Montmollin^  reported  it  7  times  in  90  cases  in 
children,  Adams»  in  11  of  337  cases  and  Setbon»  26  times  in  1501)  collected 

1  Best.  Med.  and  Surg.  Journ.,  1886,  CXXXIV,  20.-). 

2  Thtee  de  ParLs,  1897,  35. 

^  Kinderkrankheitcn,  1895,  770. 

*  Loc.  cil. 

<>  Doutsch.  mod.  Wochensch.,  1889,  1003. 

*  Jahrb.  d.  HaniburKor  Stadts  Krankenanstallcn,  1889,  I,  7. 
7  Th^.se  Nouchatci,  1885. 

«  Arch,  of  Pediat.,  1904,  XXI,  81. 
9  Th6se  de  Paris,  1902. 


408  THE  DISEASES  OF  CHILDREN 

cases.  Out  of  289  cases  of  operation  for  typhoidal  perforation  collected 
by  Elsberg^  25  occurred  in  children  less  than  15  years  of  age,  and  Jopson 
and  Gittings-  add  45  reported  cases  to  this  list.  I  have  personally 
observed  9  instances,  6  of  these  cases  previously  reported^  1  being  a  girl 
of  4  years  and  another  of  6  years.  Generally,  however,  it  occurs  only  in 
patients  near  the  end  of  later  childhood.  It  is  to  be  noted  that  the  symp- 
toms of  perforation  in  early  life  are  not  infrequently  much  less  marked 
than  in  adults  and  very  misleading,  and  that  the  diagnosis  is  often  ex- 
tremely difficult.  The  usual  fall  of  temperature  with  symptoms  of 
collapse  and  severe  abdominal  pain  may  entirel}'^  fail  to  develop.  This 
occurs  more  frequentl}^  than  is  the  case  in  adults  (Fig.  108).  Tj'-phoidal 
cholecystitis  is  probably  of  much  more  common  occurrence  than  formerly 
supposed.  It  may  rarely  exhibit  itself  in  an  acute  form  with  perforation 
and  secondary  peritonitis,  as  in  cases  reported  by  Bittner."* 

Among  nervous  complications  and  sequels  a  temporary  aphasia  is  more 
liable  to  occur  in  early  life  than  later.  Henoch"  observed  this  in  20 
of  his  381  cases.  I  have  seen  it  complete  for  several  weeks.  The 
children  sometimes  appear  to  be  suffering  not  so  much  from  inability  to 
express  their  thoughts  in  words,  as  from  a  dullness  of  mind  which  has 
removed  the  desire.  Post-typhoidal  insanity  is  a  sequel  decidedly 
rare  in  children.  Adams^  among  others,  reported  4  cases,  and  I  have 
observed  it  a  number  of  times.  Chorea  is  a  not  infrequent  sequel. 
Meningitis  is  a  very  unusual  complication,  the  great  majority  of  the  cases 
showing  symptoms  of  this  condition  being  in  reality  instances  of  pseudo- 
meningitis.  Nevertheless,  undoubted  typhoidal  meningitis  may  occur 
and  the  tj^phoid  bacilli  have  been  recovered  from  the  fluid  obtained  by 
umbar  puncture  or  from  the  meninges.  Paralysis  resulting  from  neuritis 
has  been  reported,  and  rarely  a  hemiplegia  of  cerebral  origin.  Otitis 
is  a  complication  occurring  much  more  frequently  than  in  adults.  It  is 
often  non-purulent,  producing  decided  but  temporary  deafness;  often 
purulent  with  consecutive  perforation.  Sometimes  the  deafness  appears 
to  depend  on  a  central  disturbance  rather  than  upon  otitis.  Purulent 
otitis  was  reported  in  2.7  per  cent,  of  Adams^  cases. 

Affections  of  the  genitc-urinary  apparatus  may  occur.  Nephritis  is  an 
occasional  complication  much  less  often  seen  than  in  adults.  It  generally 
recovers  as  convalescence  from  the  typhoid  fever  proceeds.  Cystitis 
and  pyelitis  are  not  common  sequels  in  early  life.  Suppurative  proc- 
esses in  various  regions  may  take  place.  One  of  the  most  troublesome 
forms  is  furunculosis,  which  may  be  very  extensive  and  severe.  Sub- 
cutaneous abscesses  are  often  observed.  Bed-sores  are  very  much  less 
frequent  than  in  adults  and  are  observed  only  in  neglected  cases  in  older 
children.  Suppuration  of  the  mesenteric  glands  may  occur,  and  cases 
have  been  reported  in  which  the  symptoms  strongly  suggested  intestinal 
perforation  (Rowland).^  Suppuration  of  the  joints  or  bones  and  necro- 
sis of  the  bones  are  occasional  sequels.  The  typhoid  spine  maj^  sometimes 
be  observed  in  early  life,  though  less  often  than  in  adults. 

Cutaneous  eruptions  sometimes  occur  as  complications.     A  rubeoloid 

1  Ann.  of  Surg.,  1903,  XXXVIII,  71. 

2  Amer.  Journ.  Med.  Sci.,  1909,  CXXXVIII,  625. 
»  Amer.  Journ.  Med.  Sci.,  1905,  Oct. 

"  Prag.  med.  Woch.,  1914,  XXXIII,  279. 

6  Kinderkrankheiten,  1895,  771. 

«  Trans.  Amer.  Fed.  Soc,  VIII,  177. 

^  Amer.  Journ.  Med.  Sci.,  1910,  Mav. 

8  Journ.  Amer.  Med.  Assoc,  1906,  XLVI,  507, 


TYPHOID  FEVER 


409 


and,  less  often,  a  scarlatiniform  rash  are  occasionally  seen,  and  sometimes 
urticaria.  These  may  be  present  either  early  or  later  in  the  attack. 
Herpes  is  rare,  but  probably  more  common  than  in  adult  life.  Other 
acute  infectious  diseases  may  complicate  typhoid  fever  or  immediately 
precede  or  follow  it.  This  is  true,  for  instance,  of  scarlet  fever,  measles, 
rubella,  varicella,  pertussis,  diphtheria,  cerebrospinal  fever,  malaria,  and 
erysipelas.  The  occurrence  of  a  secondary  diphtheria  seems  to  be 
especially  frequent. 

Relapse. — Relapse  certainly  is  not  less,  and  perhaps  more,  frequent 
than  in  adult  life.     Koplik  and  Heiman^  in  an  analysis  of  160  cases  of 


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Fig.   109. — Relapse  in  Typhoid  Fever. 
Irene    T.,  aged  9  months.     Showing  relapse  with  return  of  fever,  roseola,   and  splenic 
enlargement. 

typhoid  fever  in  children  reported  relapse  in  15  per  cent.;  and  Adams, - 
in  550  cases,  8.7  per  cent,  with  relapse.  In  my  series  of  75  cases  in  the 
first  23-2  years  of  life  there  were  3  undoubted  instances  of  relapse.  It 
develops  even  as  early  as  the  3d  or  4th,  but  oftencst  from  the  14th 
to  the  17th,  day  after  the  temperature  of  the  first  attack  has  readied 
normal.  Relapse  must,  of  course,  be  sharply  thstinfiuished  fioni  the 
recrudescnce  of  fever  which  lasts  but  a  day  or  two  and  is  brought  about 
by  many  shght  causes  (Fig.  97).  It  is  characterized  by  a  return  of 
the  usual  symptoms,  including  the  reappearance  of  the  roseola  and  of  the 
enlargement  of  the  spleen.  Not  unconiinonly  some  degree  of  splenic 
enlargement  pcMsists  during  the  afel)rile  interval.  The  relapse  may  equal, 
exceed,  or  fall  i)elow  the  first  attack  in  duration  and  severity.  It  is 
generally  of  shorter  duration.     The  age  of  the  ciiild  seems  to  exert  no 


»  Arch,  of  Ped.,  1907,  XXIV,  1. 

2  Amer.  Journ.  Med.  t?ci.,  1910,  CXXXIX,  638. 


410  THE  DISEASES  OF  CHILDREN 

decided  influence  on  the  tendency  to  its  development.  In  1  instance 
it  occurred  in  a  female  infant  of  9  months  (Fig.  109).  Even  more  than 
one  relapse  may  be  observed.  In  1  case  under  observation  3  relapses 
were  witnessed;  and  David^  reported  5  relapses  in  a  boy  of  11  years. 

Recurrence. — One  attack  of  typhoid  fever  usually  confers  lasting 
immunity.  This  is,  however,  by  no  means  so  generally  true  as  in  the  case 
of  scarlet  fever  and  measles.  The  immunity  may  be  only  a  temporary 
one.  Even  3  or  4  attacks  of  typhoid  fever  may  rarely  occur  in  the  same 
person. 

Prognosis. — The  mortality  of  typhoid  fever  in  early  life  is,  on  the 
whole,  less  than  later.  In  the  192  cases  in  children  reported  by  Schavoir^ 
only  2  died,  a  mortality  of  1  per  cent.  This  is  exceptionally  low.  In 
Morse's^  284  cases  the  mortality  was  6  per  cent,  against  that  of  13.5  per 
cent,  in  3396  adult  cases.  Of  432  cases  occurring  in  the  Children's 
Hospital  of  Philadelphia  during  14  years  23;  i.e.  5.32  per  cent.,  died. 
In  general  the  mortality  may  be  placed  at  from  4  to  5  per  cent.,  yet 
this  varies  very  much  with  the  age.  In  infancy  the  number  of  fatal 
cases  is  large.  Of  278  collected  cases'*  not  over  21^  years  of  age  57  per 
cent.  died.  Although  this  figure  is  exceptionally  high,  due  probably  to 
the  fact  that  very  many  of  the  milder  cases  were  not  considered  worthy 
of  being  reported,  and  is  not  to  be  considered  representative,  it  serves  to 
show  that  the  disease  at  this  period  is  much  more  fatal  than  later.  In 
the  later  reported^  75  cases  under  2}<2  years  the  mortality  was  12  per 
cent.  In  early  childhood  the  mortality  is  at  its  lowest  and  probably 
does  not  exceed  from  2  to  4  per  cent.  It  increases  steadily  as  the  age  of 
puberty  is  approached.  The  lesser  mortality  of  early  life  depends  in 
part  upon  the  lesser  severity  of  the  disease,  and  in  part  upon  the  lesser 
frequency  of  dangerous  complications  and  sequels. 

Among  unfavorable  prognostic  symptoms  are  very  severe  diarrhea; 
obstinate  vomiting;  persistent  dryness  of  the  tongue;  a  marked  degree  of 
tympany;  a  weak,  rapid  pulse;  and  the  development  of  unusual  degrees 
of  stuporous  mental  states  or  other  nervous  phenomena.  The  disappear- 
ance of  the  diazo-reaction  is  claimed  to  be  a  favorable  symptom,  indicat- 
ing that  a  fall  of  temperature  will  occur  in  a  few  days  (Rolleston).''  The 
slow,  irregular  pulse  of  convalescence  is  not  an  unfavorable  symptom. 

Diagnosis. — This  offers  many  difficulties  in  early  life,  especially 
in  infancy.  In  typical  cases  the  continued  fever  with  no  other  discovera- 
ble cause,  the  enlargement  of  the  spleen,  the  rose  spots,  the  agglutinative 
reaction,  the  absence  of  leucocytosis,  the  discovery  of  typhoid  bacilli 
in  the  feces,  urine  and  blood,  and  the  occurrence  sometimes  in  family 
epidemics  serve  to  render  the  diagnosis  easy,  although  it  may  be  days 
before  any  conclusion  can  be  reached.  Most  important  is  the  serum 
reaction,  and  it  is  upon  this  that  the  diagnosis  must  rest  in  many  obscure 
cases.  Yet  in  many  instances  in  which  other  symptoms  are  positive, 
the  serum  reaction  can  at  no  time  be  obtained.  This  does  not  militate 
against  the  correctness  of  the  diagnosis. 

The  absence  of  leucocytosis  is  often  a  valuable  diagnostic  sign,  but  the 
presence  of  this  condition  does  not  exclude  typhoid  fever.     The  diazo- 

1  Zentralbl.  f.  inn.  Med.,  1912,  XXXIII,  1071. 

2  Med.  Rec,  1895,  XLVIII,  803. 

3  Bost.  Med.  and  Surg.  Journ.,  1896,  CXXXIV,  205. 

*  Griffith  and  Ostheimer,  Amer.  Journ.  Med.  Sci.,  1902,  Nov. 
6  Arch,  of  Pediat.,  1912,  Aug. 
«  Lancet,  1905,  I,  290. 


TYPHOID  FEVER  411 

reaction  is  only  a  corroborative  indication  since  it  may  occur  in  some 
other  infectious  fevers.  Continued  temperature  without  evident  suffi- 
cient cause  is  alwaj's  suspicious,  but  as  this  may  develop  also  in  acute 
miliary  tuberculosis,  grippe,  ileocolitis,  low-grade  bronchopneumonia, 
and  other  conditions,  it  cannot  be  regarded  as  a  safe  diagnostic  symptom. 

Typhoid  fever  is  liable  to  be  confounded  in  early  life  with  a  number  of 
other  affections.  First  among  these,  especially  in  infancj^  is  ileocolitis. 
Diarrhea  is  quite  common  in  typhoid  fever  at  this  period  of  life  and  tym- 
panites may  occur  in  either  disease.  The  intestinal  condition  in  ileo- 
colitis is,  however,  generally  much  more  severe  and  out  of  proportion  to 
the  degree  of  fever  and  a  leucocytosis  is  generally  present.  Later  the 
discovery  of  rose  spots  with  decided  enlargement  of  the  spleen  and  a 
positive  agglutinative  reaction  may  make  the  diagnosis  of  typhoid  fever 
clear. 

Malaria  of  a  continued  febrile  type  may  simulate  typhoid  fever  very 
closely.  Leucocytosis  is  absent  in  each,  and  enlargement  of  the  spleen 
present.  The  discovery  of  the  plasmodium  and  the  absence  of  the 
Widal  and  diazo-reactions  serve  to  distinguish  malaria.  The  course  of 
the  temperature,  with  regular  intermissions  or  remissions,  is  likewise 
characteristic. 

Grippe  is,  at  times,  especially  in  the  early  stage,  readily  supposed  to  be 
typhoid  fever.  Later  the  short  course  of  the  attack  and  the  develop- 
ment of  characteristic  symptoms  s^rve  to  distinguish  it.  There  are  not 
infrequently  instances,  however,  in  which  the  fever  of  grippe  is  unusually 
prolonged,  the  prostration  decided,  and  the  symptoms  little  character- 
istic, and  these  cases  may  cause  much  perplexity.  Leucoc\'tosis  may 
be  absent  in  grippe  and  enlargement  of  the  spleen  present  in  both  dis- 
eases. The  discovery  of  the  Widal  reaction  and  of  rose  spots  will  settle 
the  diagnosis. 

Acute  miliary  tuberculosis  in  many  instances  resembles  typhoid 
fever  closely.  It  exhibits  a  fever  of  the  continued  tj'pe.  the  absence  of 
leucocytosis,  and  the  presence  of  splenic  enlargement  without  an}-  dis- 
coverable cause  or  any  localization  of  the  tuberculous  process.  The 
subcutaneous  tuberculin  reaction  cannot  be  sought  for  on  account  of 
the  continued  presence  of  fever,  and  the  cutaneous  reaction  is  not  to  be 
depended  upon  in  this  condition.  The  persistent  failure  of  the  Widal 
reaction  and  of  rose  spots  to  appear,  the  continuance  of  the  pyrexia  beyond 
the  duration  of  that  of  typhoid  fever,  and  the  possible  development  later 
of  localizing  symptoms  in  the  brain  or  the  lungs  may  finally  serve  to 
distinguish  tuberculosis.  Sometimes  a  decided  dyspnea  without  dis- 
coverable pulmonary  lesions  to  account  for  it  is  present  in  miliary  tubercu- 
losis. Occasionally  tubercles  may  be  discovered  in  the  choroid.  Often 
however,  the  diagnosis  cannot  be  made  during  life. 

A  continued  fever  oftenest  of  intestinal  origin,  dependent  probably  on 
a  mild  toxemia  the  result  of  chronic  digestive  disturlxances,  often  occa- 
sions difficulty  in  diagnosis,  especially  in  the  first  2  years  of  life.  Fever 
of  this  nature  is  liable  to  be  of  a  very  irregular  type,  and  moderate  diar- 
rhea is  often,  although  not  always,  present.  Only  careful  watching  of 
the  course  of  the  case  and  the  continued  absence  of  the  rose  spots,  enlarged 
spleen  and  Widal  reaction  serve  to  exclude  the  presence  of  typhoid  fever. 

Meningitis  may  at  first  resemble  typhoid  fever.  The  vomiting  and 
apathy  often  seen  in  the  latter  may  suggest  tuberculous  meningitis, 
while  the  cases  of  typhoid  fever  of  the  meningitic  type,  beginning  with 
convulsions  and  with  severe  cerebral  sj-mptoms,  may  point  to  cerebro- 


412  THE  DISEASES  OF  CHILDREN 

spinal  fever.  In  tuberculous  meningitis,  however,  there  is  a  tendency  to 
leucocytosis,  and  in  cerebrospinal  fever  the  leucocytes  are  very  much  in- 
creased in  number.  The  diazo-reaction  is  present  in  both  forms  of  menin- 
gitis as  well  as  in  typhoid.  The  meningitic  symptoms  of  typhoid  fever, 
however,  generally  occur  early  and  disappear  soon.  They  consist  usually, 
too,  of  symptoms  of  excitement,  and  rarely  in  children  assume  the  form  of 
paralysis  and  coma.  Kernig's  sign  is  of  little  value  as  a  differential  symp- 
tom. In  doubtful  cases  the  continued  absence  of  the  Widal  reaction  and 
the  results  of  lumbar  puncture  serve  to  distinguish  meningitis. 

Treatment.  Prophylaxis.^ — ^The  prevention  of  the  direct  spread 
of  the  disease  from  the  patient  is  to  be  sought  by  careful  disinfection  of 
the  urine  and  feces  and  of  all  the  bed  and  body  linen;  the  linen  by  sub- 
merging in  a  5  per  cent,  carbolic  acid  solution  and  afterward  by  boiling; 
the  excretions  by  mingling  them  with  this  solution  or  with  equal  parts  of 
chloride  of  lime  and  water.  The  hands  of  the  attendants  should  be 
washed  and  disinfected  after  handling  the  patient. 

The  prevention  of  extension  in  general  is,  of  course,  to  be  accomplished 
chiefly  by  the  employment  of  water  which  is  entirely  above  suspicion. 
When  this  cannot  be  obtained  all  water  to  be  used  for  drinking  and  bath- 
ing, and  for  the  washing  of  vegetables,  fruits,  eating  utensils,  nursing 
bottles  and  nipples,  and  the  like,  should  be  boiled.  The  systematic 
heating  of  milk  to  a  temperature  of  60°C.  (140°F.)  for  5  minutes  will 
destroy  any  typhoid  germs  present. 

Immunizing  Treatment. — Experimental  work  has  been  done  in  this 
line  by  Wright, ^  Pfeiffer  and  Kolle^  and  others  who  employed  injections 
of  cultures  in  which  the  germs  had  been  killed  by  heat.  The  results  re- 
ported in  the  United  States  Army  by  Russell,'  Lyster*  and  others  have 
been  and  continue  to  be  most  encouraging. 

Treatment  of  the  Attack. — This  is  purely  expectant  and  symptomatic; 
the  matter  of  the  greatest  importance  being  that  of  avoiding  an  excess  of 
it.  No  specific  treatment  has  yet  been  proven  certainly  effective,  al- 
though the  results  obtained  encourage  further  trial.  Wright'  employed 
inoculations  with  dead  bacteria,  Chantemesse'^  and  Josias^  injections  of 
an  immunizing  serum,  and  Jez,^  a  liquid  prepared  from  the  organs  of 
immunized  animals  and  given  by  the  mouth.  Good  results  are  reported 
by  all.  Favorable  results  with  the  serum  in  modifying  the  course  of  the 
attack  in  the  case  of  children  have  later  been  reported  by  Josias;^  and 
with  the  vaccine  by  Ortiz,  Acufia  and  Belloc.  ^^  Treatment  directed  to  the 
disinfection  of  the  intestinal  tract  has  not  proven  to  be  of  any  special  value. 
This  has  been  at  least  the  experience  of  many  observers  as  well  as  my 
own. 

No  matter  how  well  the  child  feels,  confinement  to  bed  is  impera- 
tive. This  need  not  be  continued  as  long  after  defervescence  as  is  com- 
monly required  with  adults.  The  diet  should  be  easily  digestible  but 
abundant,  one  in  which  milk  forms  a  prominent  part  being  the  best  in 

1  Lancet,  1901,  II,  1107. 

2  Zeitschr.  f.  Hyg.,  1896,  XXI,  203. 

3  Journ.  Amer.  Med.  Assoc,  1914,  LXII,  1371. 
'  .Journ.  Amer.  Med.  Assoc,  1915,  LXV,  510. 

5  Lancet,  1901,  I,  339. 

«  Annals  inst.  Pasteur,  1892,  VI,  755. 

'  Ann.  de  med.  et  chir.  inf.,  1903,  XI,  438. 

8  Wien  med.  Wochenschr.,  1899,  XLIX,  346. 

9  Acad,  de  m6d.,  1906,  March  6.     Ref.,  Arch.  f.  Kinderh.,  1908,  XLVII,  454. 
"  Arch,  de  med.  des  enf.,  1915,  XVIII,  575. 


TYPHOID  FEVER  413 

most  cases.  There  is  no  necessity,  however,  of  making  milk  the  only  food, 
and  a  regimen  may  well  be  used  in  which  there  is  a  high  carbohydrate 
percentage  in  the  form  of  gruels  and  the  like.  The  fancies  of  the  patient 
are  to  be  humored  as  far  as  possible,  since, 'although  over-feeding  is  to 
be  avoided,  it  is  certain  also  that  many  patients  are  under-fed.  Drinking 
water  should  be  offered  freely  and  often.  As  convalescence  begins  the 
appetite  returns,  and  the  diet  should  be  decidedly  increased  in  quantity 
and  variety.  This  may  usually  be  done  earher  than  has  been  the  custom 
in  adult  cases,  owing  to  the  lesser  degree  of  intestinal  involvement  present. 
The  increase  must,  however,  be  made  cautiously,  since  disturbance  of 
digestion  appears  undoubtedly  to  favor  the  development  of  relapse,  and 
certainly  can  cause  a  recrudescence  of  fever. 

The  surface  of  the  body  should  be  kept  clean  by  sponging  with  water 
or  alcohol  and  water,  and  the  mouth  should  be  washed  with  a  solution 
of  boric  acid  several  times  a  day.  The  need  of  the  patient  for  undisturbed 
sleep  must  be  emphasized.  It  is  well  at  night  to  lengthen  decidedly  the 
intervals  between  the  administerings  of  medicines  or  other  treatment, 
and  to  forsake  regularity,  utilizing  the  times  when  the  patient  wakes. 
Of  course  in  very  severe  cases  this  suggestion  is  not  applicable. 

Treatment  of  special  symptoms  may  next  be  considered.  Of  the 
temperature  it  is  well  to  remember  that  children  both  attain  decided 
elevation  oftener  and  endure  it  better  than  do  adults.  Consequently 
mere  elevation,  if  not  prolonged  and  if  unattended  by  unfavorable  symp- 
toms, need  not  cause  alarm,  and  does  not  require  treatment.  In  fact 
the  chief  object  of  hydrotherapy  is  not  so  much  the  reduction  of  tempera- 
ture as  the  stimulating  effect  upon  the  circulation  and  the  controlling 
of  nervous  manifestations.  Should  a  reduction  seem  indicated,  either 
sponging  or  tubbing  may  be  employed.  Where  there  is  active  objection 
on  the  part  of  the  child  to  the  use  of  water  it  will  be  found  that  tubbing  is 
not  only  more  effective  than  sponging  but  much  less  troublesome  both 
to  the  nurse  and  to  the  patient,  since  it  requires  a  shorter  time  and  causes 
no  more,  or  less,  opposition.  Sponging,  to  have  any  antipyretic  value, 
must  be  kept  up  for  from  10  to  20  minutes  and  repeated  frequently. 
Often  the  cold  or  warm  pack  is  very  efficient  and  disturbs  the  child  but 
little.  Cold  tub-baths  are,  however,  almost  never  required  and  chil- 
dren bear  them  badly.  A  graduated  bath  of  95°F,  (35°C.)  reduced  by 
the  addition  of  cold  water  to  85°F.  (29.4°C.)  is  that  most  often  serviceable. 
It  may  be  given  every  3  hours  when  the  temperature  exceeds  103°r. 
(39.4°C.),  and  continued  from  5  to  10  minutes  according  to  the  effect 
desired  and  the  tolerance  shown.  The  child  while  in  the  bath  should  be 
rubbed  vigorously  and  briskly  as  a  stimulant  to  the  circulation.  The 
head  should,  meanwhile,  be  kept  cool  by  the  repeated  application  of 
cloths  dipped  in  cold  water. 

Very  often  even  the  graduated  bath  causes  a  greater  degree  of  cyano- 
sis and  of  weakness  of  the  pulse  than  can  be  considered  safe.  In  such 
cases  the  warm  tub  bath  of  95°  to  100°F.  (35°  to  37.8°C.)  is  frequently 
very  efficacious.  Yet  not  uncommonly  even  this  is  followed  by  imperfect 
reaction  and  should  be  abandoned.  In  other  cases  the  intense  excitement 
and  opposition  shown  when  a  bath  is  given  produces  injurious  fatigue. 
In  fine,  hydrotherapy,  while  a  most  valuable  agent  in  typhoid  fever,  must 
never  be  employed  in  early  life  as  a  routine  measure  without  a  close  study 
of  its  effects  upon  the  individual  case;  otherwise  more  harm  than  good 
may  result.  If  there  is  much  shivering  and  blueness  after  the  bath  an 
alcoholic  stimulant  should  be  administered.     Frequently  it  is  advisable 


414  THE  DISEASES  OF  CHILDREN 

to  precede  it  by  this  also.  The  temperature  of  the  patient  may  be  taken 
half  an  hour  after  the  bath  is  over,  to  determine  what  degree  of  lowering 
has  taken  place. 

The  tub  bath  is  contraindicated  in  cases  of  intestinal  hemorrhage  and 
in  subjects  extremely  prostrated,  where  moving  would  be  too  exhausting. 
In  some  cases  a  satisfactory  reduction  of  temperature  may  be  obtained 
by  the  nearly  constant  application  of  an  ice-bag  to  the  abdomen,  with  one 
or  more  layers  of  towel  intervening.  In  infants  ice  must  always  be  em- 
ployed guardedly,  as  it  is  not  always  well  tolerated.  It  is  only  exception- 
ally, where  hydrotherapy  cannot  be  employed  and  where  it  is  desired 
to  reduce  unusually  high  temperature,  that  the  cautious  administration 
of  coal-tar  antipyretic  drugs  may  be  required.  In  the  cases  where  the 
terminal  stage  of  typhoid  fever  is  unusually  prolonged,  or  where  an  irregu- 
lar temperature  persists  from  causes  entirely  undiscoverable,  the  con- 
tinued employment  of  fairly  large  doses  of  quinine  is  occasionally  very 
serviceable.  Sometimes  these  patients  are  finally  most  benefited  by 
getting  them  out  of  bed  into  a  chair.  I  have  often  seen  apyrexia 
promptly  follow  this  procedure. 

Prostration  demands  stimulating  treatment,  especially  by  alcohol. 
While  the  use  of  alcohol,  as  of  stimulants  of  any  sort,  is  probably  not 
a  necessity  in  the  majority  of  cases  of  typhoid  fever,  yet  in  small  amounts 
it  is  often,  I  think,  an  excellent  conserver  of  energy.  The  condition  of 
the  heart-strength  is  the  chief  guide.  Any  degree  of  prostration,  weak- 
ness of  pulse,  nervous  exhaustion,  or  impairment  of  the  first  sound  of  the 
heart  necessitates  stimulation  by  this  or  by  other  drugs.  It  is  easier 
to  maintain  a  fair  condition  of  the  pulse  by  moderate  stimulation  than 
it  is  to  revive  it  if  it  has  commenced  to  fail  decidedly.  The  dosage  of 
brandy  or  whiskey  in  typhoid  fever  at  the  age  of  2  years  may  vary  from 
}^-2  to  1  fi.  dram  (2  to  4)  every  3  to  4  hours,  depending  upon  the  urgency. 
Cardiac  weakness  may  call  also  for  digitalis,  camphor,  caffeine  or  similar 
drugs.     This  is  true,  however,  only  of  the  bad  cases. 

Vomiting,  if  severe,  requires  that  the  milk  be  alkalinized,  diluted, 
skimmed,  peptonized,  or  entirely  replaced  for  a  time  by  other  food,  such 
as  albumen  water,  cereals,  or  broths  free  from  fat.  Frequently  it  renders 
it  advisable  to  give  drugs  hypodermically  as  far  as  possible.  Diarrhea 
need  not  be  interfered  with  if  there  are  only  4  to  5  moderate-sized  stools 
daily.  If  more  numerous,  or  if  large  and  watery,  the  condition  can  gener- 
ally be  controlled  by  small  doses  of  silver,  bismuth,  salol,  some  of  the 
tannic  acid  derivatives,  or  opium.  The  last-mentioned  drug  must  be 
given  cautiously  if  there  is  any  tendency  to  coma  or  to  decided  tympany. 
Constipation,  although  often  requiring  treatment,  is  generally  not  trouble- 
some. No  purgatives  should  be  administered  except  early  in  the  attack. 
Small  glycerine  or  larger  soap-and-water  enemata  may  be  employed. 
Glycerine  suppositories  are  often  useful.  It  need  scarcely  be  said  that 
any  injections  must  be  given  gently  without  undue  pressure. 

Tympanites  is  occasionally  sufficiently  annoying  to  demand  relief. 
The  local  application  of  turpentine  stupes  is  generally  sufficient  to  relieve 
it.  In  other  cases  the  careful  insertion  of  a  rectal  tube  is  of  benefit. 
Sometimes  injections  of  soap-and-water  or  of  milk  of  asafetida  are  use- 
ful.    Asafetida  by  the  mouth  is  frequently  serviceable  in  this  condition. 

Nervous  symptoms  at  times  require  treatment.  As  already  stated, 
hydrotherapy  is  to  be  employed  not  so  much  for  the  mere  reduction  of 
temperature  as  for  the  alleviation  of  the  attendant  nervous  phenomena. 
Delirium,  sopor,  great  restlessness,  headache,  and  the  like,  if  associated 


CEREBROSPINAL  FEVER  415 

with  high  temperature,  are  often  benefited  by  hydrotherapy.  In 
other  cases  we  may  use  small  repeated  doses  of  bromides  or  of  antipyrine 
or  phenacetin.  Sleeplessness  may  well  be  combated  by  bromides  or  vero- 
nal.    A  warm  bath  in  the  evening  may  suffice  to  relieve  it. 

Complications  and  sequels  need  treatment  appropriate  for  them.  In 
intestinal  hemorrhage  the  foot  of  the  bed  should  be  elevated,  an  ice-bag 
applied  to  the  abdomen,  and  morphine  given  hypodermically  in  sufficient 
dose  to  quiet  intestinal  peristalsis.  Epinephrine  in  doses  of  5  to  10  minims 
(0.31  to  0.62)  of  the  1:1000  solution,  given  by  the  mouth  or  subcutane- 
ously,  calcium  chloride  or  lactate  (5  to  10  grains  (0.324  to  0.648)  4  times 
daily)  or  gelatine  (10  per  cent,  solution)  may  be  tried.  Intestinal 
perforation  demands  operative  interference  at  the  earliest  possible 
moment.  The  debility  and  anemia  which  often  persist  after  severe 
cases  of  typhoid  fever  require  medication  with  iron,  strychnine  and 
other  tonics,  and  often  a  sojourn  at  the  seashore  or  in  the  mountains. 

PARATYPHOID  FEVER 

This  is  a  condition  which  has  come  into  considerable  prominence  in 
recent  years,  and  to  which  brief  reference  must  be  made.  The  disease  is 
produced  by  the  action  of  the  paratyphoid  bacillus,  either  of  the  varieties 
"A"  or  "B"  being  the  agent.  The  latter  is  that  most  frequently  found. 
Symptomatically  the  disorder  almost  exactly  resembles  typhoid  fever, 
the  chief  distinction  being  that  the  agglutinative  reaction  with  the 
typhoid  bacillus  is  absent,  while  it  is  obtained  with  the  variety  of 
the  paratyphoid  bacillus  which  is  the  causative  factor  in  the  case.  The 
affection  may  occur  isolated  or  in  small  epidemics,  and  may  affect  any 
age.  It  appears  to  be  uncommon  in  the  1st  year  of  life,  but  an  instance 
of  the  A  type  occurring  in  an  infant  of  8  months  is  reported  by  Eckert^  and 
a  number  of  instances  by  others  of  infants  with  Type  B.  A  congenital 
infection  by  the  B  bacillus  was  observed  by  Nauwerck  and  Flinzer.^  The 
lesions  appear  to  be  very  similar  to  those  of  typhoid  fever.  Decided  ulcera- 
tion of  Peyer's  patches  is  uncommon,  but  this  is  equally  true  of  typhoid 
fever  in  early  life.  Moreover  hemorrhage  and  perforation  have  been 
reported.  As  far  as  experience  has  yet  extended  the  mortality  appears 
to  be  decidedly  less  than  that  of  typhoid  fever.  The  disease  as  it  occurs 
in  infancy  and  childhood  has  been  exhaustively  reviewed  by  Cannata.* 


CHAPTER  X 

CEREBROSOINAL  FEVER 

(Epidemic  Cerebrospinal  Meningitis) 

Although  localizing  itself  largely  upon  the  cerebrospinal  meninges, 
and  belonging  with  other  forms  of  meningitis,  the  disease  is  so  manifestly 
infectious  and  often  epidemic,  with  a  complex  of  symptoms  so  peculiarly 
its  own  that  it  seems  properly  included  with  others  in  the  category 
of  Infectious  Diseases.  It  probably  existed  at  a  much  earlier  period, 
but  it  was  first  clearly  described  by  Vieusseux  in  1805"*  in  Geneva,  and 

1  Berl.  klin.  Woch.,  1910,  XLVII,  1102. 

2  Miinch.  mod.  Woch.,  1908,  LV,  1217. 

3  Annali  di  Clinica  Mcdiea,  1911,  II,  285. 

*  Hufelands,  Journ.  d.  pract.  Arzneykunde,  1805,  XIV,  3  St.,  181. 


416  THE  DISEASES  OF  CHILDREN 

shortly  afterward  in  the  United  States  (Danielson  and  Mann  ;^  Strong^) ; 
and  since  then  has  appeared  in  different  countries  with  varying  frequency. 

Etiology.  Predisposing  Causes.^ — Chmate  and  season  exert  a  decided 
influence,  the  disease  being  confined  to  temperate  chmates  and  the 
majority  of  epidemics  beginning  in  cold  weather.  Defective  sanitation 
in  general  is  likewise  important,  and  outbreaks  are  consequently  pecu- 
liarly liable  to  occur  among  soldiers  in  camps.  Trauma  of  the  head, 
exposure  to  heat,  and  mental  and  physical  over-exertion  certainly  pre- 
dispose. The  previous  health  and  the  existence  of  other  diseases  are 
without  direct  influence. 

Age  is  a  powerful  etiological  factor,  children  and  adolescents  being 
especially  susceptible,  and  infants  in  the  1st  year  being  in  no  way 
exempt.  Of  2916  cases  in  the  Silesian  epidemic  in  1905  reported 
by  Flatten^  8  per  cent,  occurred  in  the  1st  year,  47  per  cent,  from  birth  to  5 
years,  and  29  per  cent,  from  5  to  10  years.  Of  2179  cases  in  the  epidemic 
in  New  York  City  in  1904  and  1905  (Billings)"*  15  per  cent,  were  under 
1  year  and  67  per  cent,  under  10  years  of  age.  It  has  been  observed  even 
in  the  new  born  (Commandeur  and  Nordmann).^  Of  the  individual 
susceptibility  little  can  be  said  with  certainty.  It  is  undoubtedly  slight, 
since  comparatively  so  few  of  those  exposed  are  attacked.  As  a  rule  but 
a  single  case  occurs  in  a  family,  although  2  or  3  or  even  more  cases  in  a 
house  are  sometimes  seen.  Epidemic  influence  is  very  marked.  Years 
may  pass  with  but  few  cases  in  a  locality,  and  then  an  outbreak  may  occur. 
These  epidemics  are  generally  limited  in  extent,  perhaps  to  one  city,  while 
at  other  times  a  considerable  part  of  a  country,  or  even  several  countries, 
may  be  involved.  The  outbreak  nay  continue  for  months  or  years  and 
then  cease  entirely,  or  only  sporadic  cases  develop.  The  severity  of 
epidemics  varies  greatly  in  different  localities  and  on  different  occasions. 

Exciting  Cause. — The  disease  is  clearly  an  infectious  one,  now  believed 
to  be  due  to  the  diplococcus  intracellularis  meningitidis  described  by 
Weichselbaum^  in  1887,  for  although  a  symptom-complex  resembling 
that  of  cerebrospinal  fever  may  undoubtedly  be  produced  by  other 
germs,  the  disease  occurring  as  a  primary  affection  is  generally  dependent 
upon  the  meningococcus  (Councilman),^  and  cases  with  other  bacteriolog- 
ical relationships  are  better  classified  under  Simple  Acute  Meningitis. 
(See  Vol.  II,  p.  320.) 

The  germ  was  first  obtained  by  lumbar  puncture  from  patients 
during  life  by  Heubner^  who  succeeded  also  in  producing  the  disease 
in  animals  by  inoculation.  It  is  a  diplococcus,  different  in  form  from 
the  pneumococcus,  and  having  many  resemblances  to  the  gonococcus, 
failing,  as  this  does,  to  stain  by  Gram's  method,  although  not  so  invar- 
iably. It  is  found  in  large  or  small  numbers  in  the  inflammatory  exudate, 
chiefly  within  the  cells;  frequently  on  the  nasal  and  pharyngeal  mucous 
membrane,  but  only,  as  a  rule,  comparatively  early  in  the  attack;  and 
sometimes  in  the  blood.  Goodwin  and  v.  Sholly^  found  it  in  the  nose 
in  the  first  2  weeks  in  50  per  cent,  of  the  patients.     It  has  been  discovered 

1  Med.  &  Agricult.  Registry,  Bost.,  1806.     Ref.,  Osier,  Pract.  of  Med.,  1903,  101. 

2  Dissert  on  the  Disease  Termed  Spotted  Fever,  1810. 

3  Ivlin.  Jahrb.,  1905-6,  XV,  211. 

^  Journ.  Amer.  Med.  Assoc,  1906,  XLVI,  June  2. 

5  Lyon  med.,  1907,  CVIII,  1081. 

«  Fortsch.  d.  med  ,  1887,  V,  573. 

'  Journ.  Amer.  Med.  Assoc,  190.5,  XLIV,  997. 

8  Jahrb.  f.  Kinderh.,  1896,  XLIII,  1. 

9  Research  Lab.  Dept.  of  Health,  New  York  City,  1905,  I,  177. 


CEREBROSPINAL  FEVER  417 

also  on  the  conjunctiva.  Of  very  important  bearing  upon  treatment 
is  the  fact  as  pointed  out  by  Gordon^  and  others  that  there  are  different 
strains  of  the  meningococcus,  as  shown  by  their  immunological  reactions. 
Two  types  prevail,  one  responsible  for  75  to  80  per  cent,  of  the  cases 
(Flexner).- 

Vitality  of  the  Germ. — Nothing  is  definitely  determined  regarding  the 
life  history  of  the  germ  outside  the  body.  Its  vitality  appears  to  be 
slight.  It  grows  badly  on  most  culture  media,  and  it  is  readily  killed 
by  low  or  high  temperature,  or  by  drying.  Even  from  the  spinal  fluid 
the  germ  disappears  soon;  often  long  before  the  patient  has  recovered. 
Occasionally,  however,  it  persists  for  months.  In  chronic  cases  of  the 
intermittent  form  the  germ  may  sometimes  be  found  only  during  the 
exacerbations.  Sometimes  it  is  not  discovered  at  all  until  the  disease 
is  well  advanced. 

Mode  of  Transmission. — The  method  of  transmission  of  the  disease  is 
not  definitely  known.  Soil  and  water  appear  not  to  be  factors.  Whether 
it  is  carried  by  the  air  to  any  extent  is  doubtful.  Spread  of  the  infection 
by  domestic  animals  is  possible.  Only  in  rare  instances  has  the  convey- 
ance by  clothing  been  proven.  Direct  transmission  from  the  sick  to 
the  well  is  the  exception.  I  have  never  seen  a  case  develop  in  a  hospital 
ward  in  which  other  cases  of  the  disease  were  under  treatment.  Spread- 
ing by  the  schools  does  not  seem  to  occur. 

It  is  a  noteworthy  fact,  however,  that  the  microorganisms  have 
repeatedly  been  found  on  the  respiratory  mucous  membrane  of  healthy 
individuals  during  the  existence  of  epidemics,  and  it  is  very  possible 
that  dissemination  occurs  in  this  way.  Goodwin  and  v.  Sholly^  found 
them  in  the  nose  in  10  per  cent,  of  those  in  contact  with  patients,  and 
Kutscher^  in  the  nasal  and  pharyngeal  mucus  in  75  per  cent.  Other 
investigators  think  that  infection  by  the  food  is  probable.  The  7node 
of  entrance  of  the  germ  into  the  body  is  also  unknown.  The  fact  that  it 
is  often  found  on  the  nasal  mucous  membrane  of  patients  has  led  to  the 
belief  that  it  reaches  the  meninges  directly,  by  penetrating  the  cribri- 
form plate  of  the  ethmoid  bone;  others  believe  its  entrance  is  by  the  way 
of  the  lymph  vessels  from  the  nasopharynx;  and  still  others,  that  the 
portal  of  entrance  is  the  intestine. 

Pathological  Anatomy. — The  characteristic  lesion  is  an  acute 
fibrino-purulent  inflammation  of  the  pia-arachnoid  of  the  brain  and 
spinal  cord.  In  malignant  cases,  fatal  within  a  few  hours,  the  dura  and 
pia  appear  merely  intensely  congested,  swollen,  and  possibly  cloudy. 
Cellular  infiltration  may  perhaps  be  discoverable  only  with  the  micro- 
scope. In  cases  lasting  2  to  3  days  only  a  small  amount  of  purulent 
exudate  is  found.  In  the  severe  cases  which  have  continued  aUonger 
time  subarachnoid  exudate  is  evident;  at  first  simply  cloudy,  but  later 
usually  distinctly  fi])rino-purulent.  Over  the  cortex  it  occurs  oftenest  in 
streaks  following  the  fissures  and  vessels;  or  it  may  be  in  the  form  of 
scattered  yellowish  or  greenish-yellow  placques,  sometimes  covering 
the  greater  part  of  the  convexity.  It  is  generally  most  abundant  at  the 
base,  forming  a  uniform  yellowish  layer  with  much  thickening  of  the 
meninges.  The  choroid  plexus  is  involved,  and  the  ventricles  are  dilated 
by  cloudy  or  distinctly  purulent  fluid.     On  the  cord  it  is  situated  chiefly 

*  Kennedy  and  Worster-DrouKht,  Brit.  Med.  Journ.,  1917,  II,  201. 

2  Jour.  Am.  Med.  Assoc,  1918,  LXXI,  G38. 

3  Journ.  Infect.  Dis.,  190(),  Suppl.  Vol.,  21. 

*  Med.  Klin.,  1907,  III,  314. 


418  THE  DISEASES  OF  CHILDREN 

over  the  posterior  portion  and  especially  in  the  regions  below  the  cervical. 
The  spinal  nerve-roots  and  the  sheath  of  the  cranial  nerves  may  be  sur- 
rounded by  the  exudate. 

The  exudate  consists  chiefly  of  polymorphonuclear  leucocytes  in 
a  fluid,  which,  although  more  or  less  fibrinous,  is  never  so  to  the  extent 
seen  in  pneumococcic  meningitis.  In  the  acute  cases  large  cells  are  also 
discovered,  probably  derived  from  the  connective  tissue  or  the  lining  of 
the  lymph  spaces.  Meningococci,  mostly  within  the  cells,  are  present 
in  the  exudate  as  well  a-s  in  the  edematous  meningeal  tissue  which  is 
found  between  the  areas  of  distinct  cellular  infiltration.  In  chronic 
cases,  running  a  course  of  a  month  or  more,  the  exudate  has  disappeared  to 
a  large  extent,  and  its  purulent  character  given  place  to  a  condition  of  a 
more  mucous  appearance.  The  meninges  are  left  edematous  and 
thickened  and  the  ventricles  may  be  greatly  dilated. 

The  brain-tissue  itself  is  affected  to  some  extent,  being  congested 
and  softer  than  normal,  and  exhibiting  cellular  infiltration  together  with 
meningococci  in  the  superficial  layers  and  especialh^  along  the  vessels. 
In  chronic  cases  cocci  are  scarce  and  found  only  with  difficulty.  The 
cranial  nerves  are  infiltrated.  The  spinal  cord  shows  similar  changes 
but  with  fewer  cocci.  The  nerve-roots  and  nerve-ganglia  also  exhibit 
evidences  of  inflammation. 

The  bones  of  the  skull  and  the  dura  mater  of  the  brain  and  cord  are 
intensely  congested.  The  spleen  may  be  enlarged  but  is  less  often  so 
than  in  most  other  acute  infectious  diseases.  The  lungs  may  exhibit 
bronchitis,  hypostatic  congestion,  or  the  lesions  of  a  complicating  pneu- 
monia, the  consolidation  being  in  the  form  of  quite  small  foci  consisting 
of  purulent  infiltration  sometimes  distinctly  hemorrhagic  (Councilman, 
Mallory  and  Wright)  ^  and  not  developing  in  connection  with  the  bronchi. 
These  foci  may  be  scattered  or  massed  in  the  form  of  croupous  pneumonia. 

The  lesions  of  endocarditis  or  pericarditis  may  occasionally  be  found. 
The  heart,  liver  and  kidneys  exhibit  degenerative  changes,  and  sometimes 
the  lesions  of  nephritis  are  present.  Ecchymoses  in  the  skin,  punctate 
hemorrhages  in  the  endocardium,  abscesses  in  various  parts  of  the  body 
including  the  joints,  suppuration  in  the  internal  ear,  and  inflammation 
of  the  eyeball  are  sometimes  met  with. 

Symptoms.  Ordinary  Form. — The  clinical  picture  of  the  disease 
varies  greatly  in  different  subjects,  but  certain  clearly  defined  forms  are 
recognizable.  A  general  description  of  the  ordinary  type  follows: — The 
duration  of  incubation  is  not  definitely  known.  In  a  few  cases  Netter^ 
reported  it  as  between  3  and  11  days,  and  Flatten,^  in  his  studies  on  the 
Silesian  epidemic,  from  3  to  4  days  or  less.  Bolduan^  placed  it  at  from 
1  to  4  days.  It  seems  impossible  to  reach  a  positive  conclusion.  The 
attack  may  be  ushered  in  by  prodromes,  lasting  1  or  2  days,  and  consist- 
ing of  malaise,  headache, -vertigo,  chilliness,  pain  in  the  back,  and  loss  of 
appetite.  As  a  rule,  however,  the  onset  is  sudden,  with  fever,  severe 
headache,  prostration,  vomiting,  severe  pain  in  the  neck,  back  and  limbs, 
and  sometimes  convulsions  (Fig.  110).  Very  rapidly  a  peculiar  degree 
of  stiffness  of  the  neck  develops,  and  in  well-marked  cases  decided  re- 
traction of  the  head  as  well.  The  slightest  forcible  moving  of  the  head 
causes  a  cry  of  pain.     Delirium,  which  is  sometimes  violent,  great  rest- 

^  Epidem.  Cerebro-Spin.  Meningitis,  1898. 

2  20th    Cent.  Pract.  of  Med.,  XVI. 

3  Klin.  Jahrb.,  1905-6;  XV,  211. 

*  Research  Lab.,  Dept.  of  Health,  N.  Y.  Citv,  1905,  I,  140. 


CEREBROSPINAL  FEVER 


419 


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420  THE  DISEASES  OF  CHILDREN 

lessness,  and  irritability  are  common.  Sensitiveness  to  light  and  noise, 
and  cutaneous  hyperesthesia  are  marked.  As  the  disease  advances 
vomiting,  pain,  and  irregular  fever  continue,  and  more  or  less  opisthotonos 
develops.  There  is  often  rigidity  of  the  extremities.  The  face  is  con- 
gested, strabismus  or  alteration  of  the  pupils  appears,  sleep  is  disturbed, 
and  grinding  of  the  teeth  or  general  convulsions  may  occur  repeatedly. 
There  is  frequent  crying  out  with  pain.  Herpes  or  other  eruptions  of 
the  skin  may  appear,  if  they  have  not  done  so  at  the  beginning,  promi- 
nent among  them  being  those  of  a  purpuric  nature.  As  intracranial 
pressure  increases  the  pulse  becomes  slow  and  often  irregular,  the  respira- 
tion irregular,  stupor  replaces  delirium,  and  complete  coma  follows. 

The  duration  of  the  disease,  even  in  what  may  be  called  average 
cases,  is  extremely  variable.  Roughly  speaking  it  may  be  placed  at  from 
2  to  4  weeks,  not  including  convalescence,  but  may  be  much  shorter  or 
longer  than  this.  Improvement  is  characterized  by  the  diminution  of 
the  pain  and  rigidity,  permanent  lessening  of  fever,  cessation  of  vomiting 
and  improvement  of  the  mental  state. 

Some  of  the  symptoms  must  be  considered  more  in  detail. 
Convulsive  movements  are  frequent  in  infancy  and  early  childhood; 
less  so  in  older  persons.  They  may  be  general,  and  usher  in  the  attack 
and  then  cease;  or  recur  at  intervals  later,  being  then  either  general 
or  local.  Sometimes  convulsions  occur  from  time  to  time  in  the  chronic 
cases  after  most  other  symptoms  have  disappeared.  Grinding  of  the 
teeth  is  common  and  tremor  may  occur. 

Pain  is  a  very  common  symptom,  beginning  early  and  continuing 
throughout  the  acute  portion  of  the  attack.  It  is  situated  chiefly  in  the 
head,  but  may  involve  also  the  back,  abdomen  and  the  limbs,  especially 
the  lower.  It  is  subject  to  sudden  exacerbations,  especially  at  night, 
and  is  often  so  distressing  that  it  occasions  loud  outcries  (the  "hydren- 
cephalic  cry").  It  is  especially  marked  on  any  forcible  movement  of 
the  body.  General  hyperesthesia  is  very  constant,  the  patient  being 
greatly  disturbed  and  often  crying  out  on  hearing  a  loud  noise,  being 
exposed  to  bright  light,  or  on  the  mere  touching  of  the  skin. 

Muscular  rigidity  is  almost  always  seen,  chiefly  in  the  form  of  stiff- 
ness of  the  neck  and  someMegree  of  retraction  of  the  head  (Fig.  111).  If 
the  head  is  lifted  forcibly  from  the  pillow  the  trunk  follows  it  without 
any  bending  of  the  neck  taking  place.  It  can,  however,  be  turned  from 
side  to  side  without  difficulty.  In  severe,  long-continued  cases  the  occi- 
put may  even  press  against  the  back  beneath  the  scapulae  (Fig.  112). 
It  not  infrequently  happens,  however,  that  the  stiffness  of  the  neck  is  in- 
termittent, not  being  discovered  at  one  examination  although  present 
at  another.  Rigidity  with  anterior  curving  of  the  spine  is  common, 
and  the  children  often  lie  on  the  side  with  the  arms  flexed  stiffly  and 
drawn  over  the  chest,  the  legs  flexed,  and  the  thighs  drawn  to  the  ab- 
domen;— ^the  so-called  "gun-hammer"  position.  The  muscles  of  the 
face  may  be  tense  and  the  risus  sardonicus  present  (Fig.  113).  Trismus 
may  occur,  the  abdomen  is  often  scaphoid,  and  Kernig's  sign — viz.,  the 
inability  to  extend  the  leg  by  passive  movement  when  the  thigh  is  at 
right  angles  with  the  trunk — is  generally  observed,  as  in  all  forms  of 
meningitis.  The  tendon  reflexes  are  uncharacteristic,  being  either  normal, 
increased  or  absent. 

The  mental  symptoms  are  variable.  Great  restlessness  is  common 
early  in  the  attack  and  may  persist.  The  mind  may  be  clear  much  of 
the  time,  but  delirium  is  common  and  may  be  intense  or  even  maniacal, 


CEREBROSPINAL  FEVER 


421 


Fig.  111. — Opisthotonus  in  Cerebrospinal  Fever. 
Boy  of  3  years  in  the  Children's  Hospital  of  Philadelphia.     See  history  with  Fig.  117. 


Fig.  112. — Opisthotonus  in  the  Subacute  Stage  of  Cerebrospinal  Fever. 
Boy  of   1  year,  ill  for  4  or  5  weeks  with  irregular  temperature,  emaciation,  leucocytes 
33,500,  spinal   fluid  under  great  pressure  and  almost  clear,  300  cells  to  the  c.mm.,  80  per 
cent,  polymorphonuclears,  meningococci,  death. 


i  lu.    1  l.j.-lii.-^i..-^  >Sakuu.mci.>.  in  Ui.ui.iiiiosi'iNAi.  1'k\  i;u. 
Infant  of  7  months  in  the  C;hildren's  Hospital  of  Philadelphia.     Died  after  45  days  of 
illness.     Photograph  taken  on  21st  day.     Shows  the  facies  as  well  as  the  spastic  condition 
of  the  extremities. 


422 


THE  DISEASES  OF  CHILDREN 


the  child  tossing  wildly  about  the  bed,  or  even  jumping  out  of  it.  In 
other  cases  it  is  merely  of  the  wandering  type,  and  either  constant  or 
intermittent;  or  it  may  be  followed  or  replaced  even  at  the  onset  by  a 
more  or  less  apathetic  or  even  stuporous  condition.  The  degree  of 
delirium  does  not  appear  always  to  bear  any  definite  relationship  to  the 
other  symptoms  or  to  the  gravity  of  the  attack  in  general.  In  severe 
cases  coma  is  liable  finally  to  supervene,  or  it  can  even  be  one  of  the  earli- 
est symptoms.  As  in  the  case  of  delirium,  it  may  vary  greatly  from  day 
to  day,  sometimes  rapidly  disappearing  or  reappearing;  or  coma  and 
delirium  may  alternate.  The  expression  of  the  face  in  the  acute  condi- 
tion is  that  of  excitement  and  irritability,  except  in  the  mild  cases. 

Among  digestive  disturbances  vomiting  is  an  early  symptom,  present 
in  the  majority  of  cases.  It  may  be  frequent  enough  to  debilitate  the 
patient  greatly.     Generally  it  subsides  as  the  disease  advances,  but  to 


Fig.  114. — Purpuric  Eruption  in  Cerebrospinal  Fever. 
Boy  of  6}^  years,  a  patient  in  the  Children's  Ward  of  the  University  Hospital,  Phila- 
delphia.    Rash  appeared  on  the  4th  day  of  the  disease,   abundant  on  all  extremities. 
Case  a  severe  one;  improved  temporarily,  but  terminated  fatally. 

this  there  are  many  exceptions.  It  is  cerebral  in  origin,  and  may  or 
may  not  be  attended  by  coating  of  the  tongue.  Appetite  is  diminished. 
Constipation  is  generally  present. 

The  temperature  is  irregular  and  entirely  uncharacteristic.  It  generally 
rises  rapidly,  and  it  then  remains  high  or  diminishes;  but  sudden  remis- 
sions or  intermissions  as  well  as  sudden  rises  to  105°F.  (40.6°C.)  or  over 
are  liable  to  occur.  A  temperature  of  101  to  103^F.  (38.3  to  39.4°C.) 
is  an  average  one.  Some  patients  never  exhibit  much  fever.  In  fatal 
cases  unusual  hyperpyrexia  is  sometimes  seen  (Fig.  117).  As  a  rule,  how- 
ever, there  is  little  connection  in  acute  attacks  between  the  height  of 
the  fever  and  the  severity  of  the  disease.  Irregularity  is  especially 
marked  as  convalescence  goes  on,  or  as  the  disease  passes  into  a  chronic 
state. 

The  pulse  bears  little  relationship  to  the  temperature.  It  is  usually 
more  rapid  than  normal,  especially  if  there  is  great  general  debility.  It 
is  subject  to  sudden  changes  in  rate,  and  may  be  slow  or  irregular  if 
intracranial  pressure  is  increasing.     The  arterial  tension  is  low. 

The  respiration  is  not  characteristically  affected.  Its  rate  may  be 
decidedly  increased  by  the  presence  of  pain.  In  advancing  cases  it  may 
become  sighing,  irregular,  or  even  approaching  the  Cheyne-Stokes  type. 

The  cutaneous  symptoms  are  interesting;  the  most  frequent  generally 


CEREBROSPINAL  FEVER 


423 


being  herpes,  which  is  present  in  a  large  proportion  of  cases.  It  is  usually 
situated  on  the  face,  but  sometimes  elsewhere.  As  a  rule  an  early  symp- 
tom, it  may  not  develop  until  later,  or  it  may  come  out  in  crops.  A  pete- 
chial or  a  purpuric  eruption  is  common,  its  frequency  varying  greatly  with 
the  epidemic  (Fig.  114).  In  the  New  York  outbreak  of  1905  it  was  re- 
corded in  19  per  cent,  of  the  cases;  while  in  the  earlier  epidemics  in  the 
United  States  it  was  so  common  that  it  gave  rise  to  the  title  of  "  Spotted 


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Fig.  115.- 
Milton   L.,  2    years  old. 


Fig.   116. 

-Cerebrospinal  Fever,  Abortive  Fok.m. 
Onset  with  repeated    convulsions,  prolonged    unconscious- 


ness, delirium,  fever.  2d  day  showed  stuporous  condition  and  fever,  the  child  being 
apparently  very  ill.  Rapid  improvement  followed,  the  mind  becoming  quite  clear  by  the 
4th  day,  and  convalescence  being  entirely  established  by  the  8th  or  9th  day.  Meningo- 
cocci found  in  the  spinal  fluid. 

Fig.  116. — Cerebro8pin.\.l  Fever,  Mild  Form. 
Mary  K.,  aged  5  years.  One  of  three  children  of  the  family  ill  with  the  disease. 
Exact  date  of  onset  uncertain,  but  had  been  slightly  ill  for  not  over  a  week.  Feb.  23, 
sleeps  much  of  time,  mind  seems  entirely  clear,  e.xpression  placid,  apparently  no  pain,  no 
irritability,  no  hyperesthesia,  abdominal  tache  marked,  neck  slightly  stiff,  head  slightly 
retracted  but  only  if  the  child  lies  on  her  side,  no  other  rigidity,  no  herpes  or  petechia; 
Feb.  26,  improving,  much  brighter;  Feb.  28,  greatly  better,  stiffness  of  neck  gone; 
Mar.  10,  out  of  bed,  entirely  well.     No  serum  used.     Children's  Hospital  of  Philadelphia. 


Fever."  In  the  epidemic  in  Philadelphia  in  1917  and  1918  I  observed 
it  in  comparatively  few  cases.  It  may  appear  early  or  later,  and  seems 
to  bear  little  relation  to  the  severity  of  the  attack.  In  some  cases  larger 
cutaneous  hemorrhages  occur.  A  well-marked  tciche  cerebrale  is  a  common 
symptom,  as  in  all  forms  of  meningitis,  and  often  there  may  be  noted  an 
irregular  flushing  of  the  trunk  when  exposed,  or  of  the  face,  the  evi- 
dence of  the  vasomotor  disturbance  present  (see  Vol.  II,  p.  322,  Fig.  340). 


424 


THE  DISEASES  OF  CHILDREN 


In  any  case  at  all  long-continued   emaciation  is  very  decided   and   in 
chronic  cases  is  liable  to  become  extreme. 

The  blood  always  presents  an  early  and  very  decided  leucocytosis, 
especially  of  the  polymorphonuclear  cells,  equalling  sometimes  as  much 
as  40,000  or  more  to  the  c.mm.  The  eosinophiles  disappear.  The 
urine  is  normal  or  exhibits  a  febrile  albuminuria.  Small  amounts  of 
sugar  are  occasionallj'  observed. 


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Fig.  117. — Cerebrospinal  Fever,  Severe  Form,  Long  Course. 
Howard  .S.,3  years  old.  Admitted  to  the  Children's  Hospital  Mar.  2, 1917.  Onset  with 
fever,  vomiting  and  headache  on  Feb.  27.  On  admission  rigidity  of  neck,  irritable  when  dis- 
turbed, increased  knee-jerks,  Kernig's  sign,  hyperesthesia,  cloudy  fluid  containing  menin- 
gococci. While  in  hospital  had  continued  retraction  of  head,  widespread  petechise, 
stupor,  hyperesthesia,  sometimes  very  restless.  Lumbar  puncture  and  injection  of  serum 
done  repeatedly,  but  seemed  to  produce  severe  reaction,  with  prostration.  Restlessness 
and  irritability  increased  after  serum  injected.  Examinations  of  blood  at  different  times 
showed  leucocytes  varied  from  12,000  to  23,000;  Mar.  11,  appeared  to  be  improving,  but 
relapsed.  Washing  out  of  spinal  canal  with  salt  solution  tried  on  the  last  few  days  of  life, 
but  child  grew  worse.     Death  on  Mar.  21. 

The  eyes  may  show  injection  or  decided  inflammation  of  the  conjunc- 
tiva. The  pupils  are  often  variable  at  first,  and  dilated  later  or  react 
slowly.     Strabismus  is  common  and  nystagmus  may  occur. 

The  cerebrospinal  fluid  as  obtained  by  lumbar  puncture  is  increased  in 
amount;  turbid  in  acute  cases  and  often  quite  purulent;  and  exhibits  an 
increase  of  globulin.  It  contains  numerous  polymorphonuclear  leuco- 
cytes together  with  meningococci  in  varying  numbers,  free,  or  principally 
within  the  cells.  The  germs  frequently  disappear  early  in  the  attack, 
and  in  more  chronic  cases  the  fluid  may  be  almost  or  quite  clear,  and 
without  any  preponderance  of  polymorphonuclear  cells,  and  meningo- 
cocci can  usually  no  longer  be  discovered.  Not  infrequently  a  fluid, 
purulent  at  first,  rapidly  becomes  nearly  or  quite  clear,  to  exhibit  a  re- 
turn of  the  purulent  condition  later,  if  recovery  is  not  prompt. 


CEREBROSPINAL  FEVER  425 

Variations  from  the  Ordinary  Form. — Even  among  cases  of  the 
ordinary  type  there  is  the  greatest  variation  in  the  symptoms.  Some 
begin  with  very  severe  manifestations  which  soon  ameliorate.  The 
patients,  however,  may  fail  to  convalesce  at  once,  but  pass  perhaps 
through  weeks  of  illness  of  much  diminished  severity.  Other  cases  begin 
mildly  but  soon  grow  more  severe.  Others  reach  a  fatal  ending  through 
some  one  of  the  numerous  complications  which  are  prone  to  develop. 
The  variations  are  often  so  decided  that  a  number  of  special  types  are 
described.  Among  these  may  be  mentioned  (1)  the  Abortive  form; 
(2)  the  Mild  form;  (3)  the  Severe  form;  (4)  the  Malignant  form;  (5) 
the  Chronic  form;  and  (6)  the  Intermittent  form. 

1.  Abortive  Form. — In  this  variety  the  disease  begins  abruptly  and 
severely,  but  in  2  or  3  days  the  threatening  symptoms  disappear  and  the 
patient  rapidly  recovers  (Fig.  115). 

2.  Mild  Form. — In  cases  of  this  sort  the  symptoms  are  mild  from  the 
outset,  or  soon  become  so  after  a  severe  onset  (Fig.  116).  There  may  be 
only  slight  headache  and  nausea,  occasional  vomiting,  slight  stiffness 
and  pain  in  the  neck,  and  little  fever.  The  mind  is  clear,  or  nearly  so. 
The  patient  may  not  even  be  confined  to  bed.  Sometimes  the  symptoms 
are  so  trivial  and  uncharacteristic  throughout  that  diagnosis  would  be 
impossible  if  the  case  were  an  isolated  one.  In  1  case  of  3  occurring 
simultaneously  in  a  family  under  my  care  the  only  symptoms  present 
were  slight  fever  and  cerebral  tache  and  a  slight  ridigity  of  the  neck;  all 
of  which  would  have  passed  unnoticed  had  the  case  occurred  alone.  In 
another  instance,  also  1  of  a  family  group  of  3,  the  patient  was  suffer- 
ing from  a  mild  attack  of  pneumonia;  only  the  tache  and  the  very  moder- 
ate rigidity  of  the  neck  indicating  that  this  disease  was  a  complication  of 
a  very  mild  cerebrospinal  fever. 

3.  Severe  Form  (Fig.  117). — In  this  all  or  many  of  the  symptoms  are 
intensified.  The  type  does  not  differ  materially  from  that  described  as 
the  ordinary  variety,  except  for  a  greater  severity  of  the  manifestations. 
The  course  may  be  short  or  prolonged. 

4.  Malignant  or  Fulminating  Form  (Figs.  118  and  119). — This 
variety  is  characterized  by  the  extremely  sudden  onset,  the  intensity'  of 
the  symptoms,  the  tendency  to  severe  collapse,  and  the  shortness  of  the 
course.  The  child  may  be  stricken  suddenly  while  at  play.  It  may 
suffer  from  repeated  convulsions  and  die  in  less  than  24  hours,  the  diagno- 
sis being  impossible  unless  the  case  be  one  of  a  family  group  or  a  lumbar 
puncture  be  made.  Sometimes  coma  and  collapse  are  the  earliest  or 
the  only  symptoms,  or  there  may  be  most  violent  repeated  vomiting  or 
intense  headache.  Widespread  cutaneous  hemorrhages  may  develop 
and  hemorrhage  from  the  mucous  membranes  take  place. 

5.  Chronic  Form. — This  might  be  called  one  of  the  terminations 
of  the  disease.  The  symptoms  at  first  do  not  differ  from  those  of  the 
ordinary  type.  Instead,  however,  of  disappearing  gradually,  they  con- 
tinue in  a  modified  form.  Fever  may  be  absent  for  a  considerable 
time  and  ail  the  symptoms  may  ameliorate.  Then,  with  the  recurrence 
of  elevated  temperature  the  stiffness  of  the  neck  increases,  vomiting 
returns,  delirium  or  stupor  reappears,  and  convulsions  may  occur.  This 
condition  may  last  a  variable  time,  to  be  followed  ap|)aiontIy  l)y 
the  beginning  of  certain  convalescence,  when  a  second  recurrence  takes 
place.  In  this  way  the  disease  may  be  protracted  for  months.  Not  all 
the  symptoms  mentioned  need  be  present.  In  fact,  the  symptomatology 
is  likely  to  be  very  variable.     In  some  cases  the  remissions  in  tempera- 


426 


THE  DISEASES  OF  CHILDREN 


ture  are  unattended  by  improvement  in  other  symptoms.  Emaciation 
is  liable  to  become  extreme.  I  have  'the  record  of  1  case,  finally  fatal, 
lasting  251  days.  During  much  of  this  period  the  child  seemed  at  inter- 
vals almost  entirely  well.  The  sections  of  the  case  history  appended 
(Figs.  120  to  124)  give  a  synopsis  of  the  symptoms  as  occurring  at  different 
times  in  the  course  of  the  disease.  There  is  no  disorder  more  discouraging 
to  the  family  and  the  physician  than  this  chronic  form  of  cerebrospinal 
fever.  (See  Sequels,  below.)  There  is  also  a  condition  occurring  in  infancy 
known  as  chronic  basilar  meningitis  which  is  probably  a  variety  of  chronic 
cerebrospinal  fever.     (See  also  Chronic  Meningitis,  Vol.  II,  p.  336.) 


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Fig.  119. 


Fig.  118. — Cerebrospinal  Fever,  Malignant  Form. 
Charles  K.,  2  years  old.     One  of  three  in  family  with  the  disease.     Taken  ill  suddenly 
on  Feb.  22  with  convulsions,  and  these  continued  without  interruption.      Death  on  the 
afternoon    of    Feb.    23    without    having    regained    consciousness.     Children's    Hospital, 
Philadelphia. 

Fig.  119. — Cerebrospinal  Fever,  Malignant  Form. 
Ethyl  C,  9   months  old.     Feb.  5,  taken  ill  suddenly  in  the  afternoon  with  vomiting 
lasting  an  hour.     Then  became  drowsy,  weak,  and  with  rapid  respiration;  Feb.  6,  stuporous, 
rolling  of  eyes,  rigidity  of  arms  and  legs,  cyanosis,  leucocytosis  15,200.     Meningococci  in 
the  spinal  fluid.     Death  in  the  afternoon. 

6.  Intermittent  Form  (Fig.  125). — This  is  in  reality  one  of  the  varie- 
ties of  the  chronic  type,  characterized  by  a  temperature  curve  which 
strongly  suggests  malarial  fever.  There  are  not  the  longer  and  irregu- 
lar periods  of  freedom  from  fever  characteristic  of  the  variety  just  de- 
scribed. Improvement  in  symptoms  may  or  may  not  attend  the  drops 
in  temperature. 

Complications  and  Sequels. — These  are  numerous  and  often  of  a 
very  serious  character,  being  even  the  direct  cause  of  death  or  of  perma- 


CEREBROSPINAL  FEVER 


427 


nent  disability.  The  most  important  are  those  affecting  the  nervous 
system  and  the  special  senses.  The  eyes  may  exhibit  neuritis  of  the  optic 
nerve,  due  to  involvement  by  the  exudate  at  the  base  of  the  brain,  or 
the  purulent  process  may  extend  along  the  pia-arachnoid  of  the  nerve 
and  produce  a  purulent  choroido-iritis.  In  other  cases  a  neuritis  of  the 
fifth*  nerve  is  followed  hx  purulent  conjunctivitis  or  keratitis.     These 


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Fig.   120. — Cerebrospinal  Fever,  Chronic  Form. 
Willie  R.,  6j^  years  old.     Children's  Hospital.      Chart  of  oth  to  15th  day  inclusive. 

I.  Acute  Stage. — Nov.  11,  1904.  Irritability,  delirium,  pain  in  neck,  back  and  limbs, 
strabismus,  rigidity,  retraction  of  head,  hyperesthe.sia,  leucocytosis  19,520.  Lumbar 
puncture  showed  thick  pus  with  meningococci;  Nov.  16,  gradual  improvement;  Nov.  18, 
rational  to  a  considerable  degree;  Nov.  21,  petechiie;  Nov.  26,  improving  decidedly,  slight 
hyperesthesia  and  some  rigidity  and  pain  remaining. 

Fig.  121. — Cerebrospinal  Fever,  Chronic  For.m. 
Willie  R.  (Continued).     Chart  of  36th  to  46th  day  inclusive. 

II.  Partially  Intermittent  Temperature. — General  condition  in  December  much 
improved.  Still  strabismus,  slight  stifTness  of  neck,  and  frequent  pain  in  the  limbs  and 
back.     Began  to  walk  by  the  end  of  December. 


lesions  may  develop  early  or  later  in  the  attack.  Complete  or  partial 
blindness  may  result.  The  ears  are  very  often  involved.  Westenhoffer^ 
believes  that  otitis  media  is  present  in  all  cases  in  children.  If  purulent 
it  may  be  the  cause  of  loss  of  hearing.  Absolute  deafness  from  inflam- 
mation of  the  labyrinth,  resulting  from  extension  of  the  process  along 
the  auditory  nerve,  is  a  not  infrequent  sequel.     ]\Ioos'-  found  38  deaf- 


1  Klin.  .Jahrb.,  1905-6,  XV,  657. 

"^  Die  Taubstuinmheit  in  ihrer  AbhtinKigkeit  m.  Cercbr.-sp.  Mening.,  1883. 
Councilman,  Mallory  and  Wright,  loc.  cit. 


Ref., 


428 


THE  DISEASES  OF  CHILDREN 


mutes  in  64  recovered  cases  of  cerebrospinal  fever.  Probably  the  ma- 
jority of  cases  of  deaf-mutism  in  institutions  owe  their  origin  to  this 
disease. 

Disordered  mental  states  may  occur  as  sequels,  among  them  being  apha- 
sia and  mental  impairment.  Among  539  cases  of  mental  defect  in  Nor- 
way, reported  by  Looft^  3.7  per  cent,  resulted  from  cerebrospinal  fever. 
Headache  is  sometimes  very  persistent.  Hydrocephalus  is  a  serious  and 
ver}^  frequent  sequel.  Undoubtedly  many  of  the  chronic  cases  of  cerebro- 
spinal fever  are  due  to  it.      The  group  of  symptoms   characterizing  it 


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Willie  R.  (Continved).     Chart  of  89th  to  09th  day  inclusive. 

III.  Apparent  Convalescence,  Followed  by  Some  Return  of  Symptoms. — During  last  of 
December  and  January  child  constantly  improving.  Out  of  bed  and  walking  about  the 
room.  Strabismus  and  slight  rigidity  of  neck  remained.  Last  of  January  frequent 
vomiting  began.  Occasionally  slight  convulsions.  Child  looked  less  well.  Leucocytes 
increased  from  14,350  on  Feb.  1  to  17,050  on  Feb..  13.     Practically  no  fever. 


as  outlined  by  Ziemssen^  and  others,  consists  of  vomiting;  severe  pain  in 
the  head,  neck,  and  limbs;  rigidity;  great  emaciation;  increasing  apathy; 
convulsions;  and  finally  coma.  This  condition  may  alternate  with 
periods  of  decided  improvement  in  health.  Hydrocephalus  of  an  acute 
form  may  occur  even  early  in  the  disease.  This  would  account  for 
some  of  the  symptoms  observed  at  that  period.  Paralysis  may  involve 
the  eyes  or  the  face;  less  often  the  limbs,  in  the  latter  case  being  either 
hemiplegic  or  paraplegic  in  type.  It  may  be  temporary  or  permanent. 
It  generally  does  not  develop  until  well  on  in  the  attack. 

Inflammation  of  the  pharynx,  nasopharynx,  and  tonsils  is  a  frequent 

1  Nord.  med.  Ark.,  1901,  II,  No.  4. 

2  Hand.  spec.  Path.  u.  Therap.,  Bd.  II,  Th.  II,  683. 


CEREBROSPINAL  FEVER 


429 


complication  occurring  early  in  the  "attack,  and  sometimes  antedating 
other  symptoms.  Pneumonia  is  frequently  combined  with  meningitis. 
When  it  is  the  primary  disease  it  is  pneumococcic  in  origin  and  the 
meningitis  is  probably  of  the  same  nature  and  not  to  be  classed  as  cere- 
brospinal fever.  Pneumonia,  however,  is  frequently  seen  as  a  comphca- 
tion  secondary  to  cerebrospinal  fever,  and  probably  is  produced  by  the 
meningococcus.  Nephritis  is  a  serious  complication  occasionally  seen 
adding  to  the  gravity  of  the  case.     Although  not  reported  so  frequent 


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Fig.  124. 


Fig.  123 — Cerebrospinal  Fever,  Chronic  Form. 
Willie  R.  {Continued).     Chart  of  118th  to  124th  day  inclusive. 

IV.  Continuance  of  Subacute  Symptoms. — Mar.  1,  child  again  confined  to  bed.  Fre- 
quent distressing  pain  in  head,  neck,  and  limbs,  emaciation  decided,  losing  power  in  limbs, 
irritable  and  capricious  but  mind  clear,  slight  febrile  reaction.  Sedatives  constantly 
required. 

Fig.  124. — Cerebrospinal  Fever,  Chronic  Form. 
Willie  R.  {Continued) .     Chart  of  245th  to  251st  day  inclusive. 

V.  Gradual  Increase  of  Hydrocephalic  Symptoms. — Slow  but  constant  loss  of  strength 
continued,  pain  very  frequent  and  distressing,  emaciation  extreme.  In  July,  failed  rapidly, 
rigid  all  over,  head  much  retracted,  periods  of  unconsciousness  and  finally  persistent  coma. 
Died  July  15,  on  the  251st  day  of  the  disease. 

by  most  writers,  Steiner  and  Ingraham^  found  evidence  of  its  presence 
in  28  out  of  145  cases  of  the  disease.  Arthritis  affecting  a  number  of 
joints  is  a  not  infrequent  complication  or  sequel.  The  fluid  may  be 
serous  or  purulent  in  nature  and  contain  the  meningococcus.  In  other 
cases  the  joint  is  red  and  swollen  without  evidence  of  effusion. 

Cerebrospinal  fever  may  occasionally  occur  simultaneously  with  or 
as  a  sequel  to  other  acute  infectious  diseases,  among  these  being  typhoid 

'  Amcr.  Journ.  Med.  Sti.,  1908,  CXXV,  351. 


430 


THE  DISEASES  OF  CHILDREN 


fever,  scarlet  fever,  measles  and  diphtheria.     Collins^  reports  an  instance 
of  the  combination  of  this  disease  with  malaria. 

Among  other  complications  sometimes  seen  are  plem'isy,  pericarditis, 
endocarditis,  peritonitis,  parotitis,  enteritis,  subcutaneous  abscesses, 
urticaria,  pemphigus,  and  erythema. 


Relapse. — In  a  disease  with  such  an  uncertain  course  and  with  such 
a  natural  tendency  to  recrudescence  after  convalescence  is  apparently 
beginning,  it  is  difficult  to  reach  any  conclusion  regarding  the  frequency 
of  relapse.  Indeed,  the  disposition  to  it  may  be  called  a  part  of  the 
disease. 

1  Boston  Med.  and  Surg.  Journ.,  1911,  CLXV,  610. 


CEREBROSPINAL  FEVER  431 

Recurrence. — Little  is  known  about  recurrence.  As  a  rule  one 
attack  appears  to  protect  from  subsequent  ones,  although  instances  to 
the  contrary  are  reported. 

Prognosis. — The  disease  is  a  serious  one,  the  mortality  varying 
according  to  Hirsch^  from  20  per  cent,  to  75  per  cent.,  and  being  oftener 
nearer  the  latter  figure  than  the  former.  The  actual  number  of  cases 
dying  during  epidemics  is  often  large,  over  2500  having  succumbed  in 
New^York  City  in  the  outbreak  of  1904-1905  (Billings). ^  The  mortality 
is  especially  high  in  early  life.  Friis^  found  it  in  the  1st  year  to  be  77.7 
per  cent.,  from  1  to  5  years,  48.7  per  cent.,  from  5  to  10  years  51.6  per 
cent.,  and  from  10  to  15  years  21.4  per  cent.  Of  779  fatal  cases  collected 
by  Hirsch^  208  were  under  1  year  of  age,  337  from  1  to  5  years,  151  from 
5  to  10  years,  41  from  10  to  15  years,  16  from  15  to  20  years,  and  26  over 
20  years  of  age.  It  is  impossible  to  predict  what  the  outcome  will  be  in 
any  given  case,  and  the  prognosis  must  always  be  very  guarded.  The 
fulminant  cases  are  nearly  always  fatal.  Sudden,  severe  onset;  very 
exhausting  and  continued  vomiting;  persistent,  unusually  high  tempera- 
ture; the  repeated  occurrence  of  convulsions;  rapid  pulse  and  respiration, 
and  the  early  development  of  coma  or  its  long  persistence  are  unfavorable 
symptoms.  A  drop  in  the  number  of  neutrophiles  in  the  blood  and  an  in- 
crease of  the  lymphocytes  is  a  favorable  indication.  Death  takes  place 
oftenest  within  the  1st  week,  and  the  outlook  is  consequently  brighter 
when  the  2d  week  is  well  under  way  and  the  symptoms  seem  to  be  amelior- 
ating. To  this,  however,  there  are  numberless  exceptions,  since  a  long- 
continued  chronic  form  frequently  develops  which  ends  fatally  oftener 
than  in  recovery.  There  is  always,  too,  the  very  great  danger  of  perma- 
nent sequels  remaining.  Epidemic  influence  upon  the  mortality  is 
marked,  the  number  of  deaths  being  much  greater  in  some  years  than  in 
others.  More  fatal  cases  occur  at  the  beginning  of  an  epidemic  than 
later. 

What  has  been  said  above  regarding  the  mortality-rate  applies  only 
to  the  condition  before  serum-treatment  was  commenced.  This  will 
be  discussed  under  Treatment. 

Diagnosis. — This  rests  especially  on  the  sudden,  severe  onset, 
vomiting,  delirium,  restlessness,  intense  headache,  stiffness  and  pain  in 
the  neck,  retraction  of  the  head,  pain  in  and  rigidity  of  the  muscles  of 
the  back  and  limbs,  leucocytosis,  herpes,  the  rapid  development  of  the 
symptoms  early  in  the  attack,  and  the  great  tendency  to  variation  in  its 
course.  All  these  are  indications  of  the  presence  of  some  variety  of  men- 
ingitis, but  in  no  other  is  there  such  a  striking  complex  of  symptoms.  The 
spinal  manifestations  are  generally  more  marked  than  in  any  other  form. 
In  the  malignant  cases  the  diagnosis  may  be  impossible.  This  is  true  also 
of  the  very  mild  cases  without  suggestive  symptoms.  The  existence  of 
an  epidemic  is  often  of  great  service  in  reaching  a  conclusion,  but  the 
individual  character  of  the  epidemic  is  to  be  borne  in  mind.  In  that  in 
Philadelphia  in  1917  the  diagnosis,  although  easy  in  many  cases,  was  in 
others  very  confusing.  In  some  instances  the  early  symptoms  were  so 
entirely  uncharacteristic  that  only  the  fact  that  the  disease  was  prevailing 
led  to  the  performing  of  lumbar  puncture,  and  the  discovery,  based 
only  on  this,  that  meningitis  existed.     Percussion  of  the  skull,  rccom- 

'  Die  Meningitis  cerebrospinalis  epiclcmica,  1866,  33. 

2  Journ.  Anier.  Med.  Assoc,  1906,  XLVI,  June  2. 

'  Ugerskrift  for  Laeger,  1891,  Ref.    Netter,  20th  Cent.  Pract.  of;. Med.,  XVI. 

*  Loc.  cit. 


432  THE  DISEASES  OF  CHILDREN 

mended  by  Macewen,  for  the  discovery  of  fluid  in  the  ventricles  is  strongly 
urged  by  Koplik/  a  slightly  tympanitic  note  in  the  lateral  regions 
indicating  the  presence  of  fluid. 

The  character  of  the  spinal  fluid  is  most  important  diagnostically. 
The  early  purulent  nature  distinguishes  it  from  tuberculous  menin- 
gitis, in  which  the  fluid  is  clear  or  only  slightly  opalescent.  There  is  the 
contrast,  too,  between  the  numerous  polymorphonuclear  cells  of  cere- 
brospinal fever  and  the  lymphocytic  cells  usually  predominating  in  cases 
of  tuberculous  meningitis.  In  the  more  chronic  cases  the  fluid  may  be 
clear,  but  by  this  time  the  distinction  from  tuberculous  meningitis  can 
generally  be  made  readily  in  other  ways.  The  distinguishing  of  the  fluid 
of  meningococcic  meningitis  from  that  of  other  acute  purulent  forms  can 
be  done  only  by  bacteriological  study. 

Cerebrospinal  fever  is  to  be  differentiated  from  several  other  forms 
of  meningeal  inflammation.  Tuberculous  meningitis  comes  on,  as  a  rule, 
very  slowly  and  insiduously  with  only  a  later  development  of  marked 
cerebral  symptoms  and  finally  of  coma,  and  is  without  the  rapidity  of 
alteration  in  the  symptoms  to  the  degree  characteristic  of  cerebrospinal 
fever.  These  diagnostic  differences  apply,  however,  only  to  typical 
cases  of  the  disease;  in  others  the  differentiation  based  on  symptoma- 
tology, apart  from  lumbar  puncture,  may  be  impossible. 

Simple  acute  meningitis,  in  the  sense  of  being  due  to  germs  other  than 
the  meningococcus,  may  simulate  cerebrospinal  fever  so  closely  that 
diagnosis  cannot  be  made  except  by  lumbar  puncture.  Spinal  symptoms, 
however,  are  generally  less  often  present  and  the  existence  of  some  evident 
cause  is  often  discoverable,  since  the  disease  is  usually  a  secondary  one. 
It  is  always,  too,  of  a  severe  form  and  generally  fatal;  and  consequently 
the  diagnosis  from  milder  cases  of  cerebrospinal  fever  is  usually  made 
easily.  It  seems  very  probable,  as  Still^  has  maintained,  that  the  pos- 
terior basic  meningitis  first  described  by  Gee  and  Barlow^  as  occurring 
in  infants  is,  in  reality,  cerebrospinal  fever,  since  the  microorganisms 
are  practically  identical. 

Cerebrospinal  fever  may  be  confounded  with  several  diseases  which 
present  no  lesions  of  the  meninges.  Prominent  among  these  is  typhoid  fever 
of  the  meningitic  type.  As  a  rule  the  passage  of  time  will  make  the 
diagnosis  easy,  although  there  are  certainly  exceptions  to  this.  The 
meningitic  symptoms  generally  soon  disappear  in  typhoid  fever  and  other 
characteristics  become  evident,  especially  the  absence  of  leucocytosis  and 
the  presence  of  the  Widal  reaction.  The  mere  presence  of  leucocytosis, 
however,  aids  but  little,  since  this  may  occur  in  typhoid  fever  as  the  result 
of  some  complicating  condition.  Occasionally  grippe  exhibits  symptoms 
resembling  those  of  cerebrospinal  fever  so  closely  that  only  lumbar  punc- 
ture can  settle  the  diagnosis.  Yet,  as  a  rule,  cases  of  this  disease  with 
meningitic  symptoms  exhibit  a  shorter  course  and  no  retraction  of  the 
head.  The  high  degree  of  leucocytosis  in  meningitis  is  also  of  diagnostic 
value  in  excluding  grippe.  It  is  to  be  borne  in  mind  that  a  true  influenzal 
meningitis  is  sometimes  observed.  Pneufnonia  may  be  ushered  in  with 
symptoms  simulating  meningitis.  The  examination  of  the  blood  does  not 
aid,  since  both  conditions  exhibit  a  high  leucocytosis.  The  course  of 
the  case  will  make  the  diagnosis  clear.  It  is  to  be  remembered,  however, 
that  an  actual  meningitis  may  occur  in  combination  with  pneumonia, 

1  Amer.  Journ.  Med.  Sci.,  1917,  CXXXIII,  547. 

2  Journ.  Path,  and  Bact.,  1898,  V,  147. 

3  St.  Barth.  Hosp.  Rep.,  1878,  XIV,  23. 


CEREBROSPINAL  FEVER  433 

either  of  a  serous  or  less  often  a  pneumococcic  nature.  In  suspected  cases 
lumbar  puncture  may  settle  the  question  as  to  the  presence  of  meningitis 
and  the  character  of  any  germs  found.  Autointoxication  of  gastrointes- 
tinal origin  may  begin  with  vomiting  and  meningeal  symptoms  and  be  the 
cause  of  considerable  uncertainty  of  diagnosis  for  a  time.  As  a  rule 
however,  the  nature  of  the  case  soon  becomes  evident. 

Treatment.  Prophylaxis. — With  our  ignorance  of  the  method  of 
extension  of  the  disease,  preventive  treatment  seems  as  yet  almost  im- 
possible. The  isolation  of  affected  persons  is  desirable  in  spite  of  the 
lack  of  evidence  of  direct  communicability.  The  employment  of  mild 
disinfectant  nasal  sprays  in  the  case  of  those  known  to  have  been  exposed 
is  also  to  be  recommended,  in  view  of  the  possible  carrying  of  the  disease 
by  healthy  persons. 

Treatment  of  the  Attack. — Except  as  regards  the  serum-treatment, 
this  is  largely  symptomatic.  The  patient  should  be  kept  very  quiet 
in  a  darkened  room,  in  order  to  combat  the  excessive  hyperesthesia. 
As  the  disease  is  a  depressing  one,  the  strength  should  be  maintained  by 
sufficient  nourishment,  not  necessarily  liquid,  and  often  by  alcoholic 
and  other  stimulants,  given  freely  if  need  be.  Although  vomiting  may 
render  feeding  difficult  and  a  modification  of  the  choice  of  food  necessary, 
it  is  to  be  remembered  that  this  symptom  is  cerebral  in  origin,  not  de- 
pendent upon  indigestion.  Comatose  patients  should  be  fed  by  gavage. 
Digitalis  is  frequently  required.  Strychnine  is,  in  my  opinion,  better 
avoided,  as  it  seems  sometimes  to  increase  the  excitability.  Bromides 
are  often  useful  to  quiet  the  patient,  but  the  best  drug  for  this  purpose 
and  for  the  relief  of  pain  is  morphine  given  hypodermically,  taking  care  not 
to  precipitate  or  increase  a  tendency  to  coma.  Inunctions  of  mercurial 
ointment  have  been  recommended.  The  employment  of  an  ointment 
or  of  suppositories  of  colloidal  silver  has  been  advocated  and  may  be 
tried.  I  have  never  been  able  to  convince  myself  of  any  actual  benefit 
being  obtained. 

Blisters  to  the  back  of  the  neck  serve  only  to  increase  the  discomfort. 
Warm  baths  at  100°F.  (37.8°C.)  are  useful  to  quiet  nervousness.  An  ice- 
bag  may  be  applied  to  the  head,  remembering,  however,  the  danger  of 
depression  by  this  treatment  in  the  case  of  little  children.  In  the  later 
stages  the  administration  of  iodides  is  recommended  to  favor  absorption 
of  meningeal  thickening. 

The  removal  of  the  exudate  by  lumbar  puncture  often  gives  surprising 
relief  if  the  symptoms  indicate  cerebral  pressure.  It  should  be  employed 
in  all  such  cases.  The  injection  through  the  needle  of  a  1  per  cent,  solu- 
tion of  lysol  has  been  recommended  by  Franca^  but  has  not  met  with 
general  acceptance.  Inasmuch  as  the  inflammation  often  shuts  off  the 
cranial  cavity  from  the  spinal  cord,  lumbar  puncture  frequently  fails  to 
relieve  the  cerebral  symptoms.  In  such  cases  tapping  of  the  ventricles 
was  advocated  by  Schultz^  and  is  often  serviceable. 

Serum-Treatment. — Kolle  and  Wassermann,^  Jochmann,^  Flexner 
and  Jobling,^  Dopter^  and  others  have  prepared  a  serum  for  use  in  this 
disease.     That  made  by  Flexner  and  Jobling  is  obtained  from  horses 

1  Deut.  med.  Wochenschr.,  190G,  XXX II,  (J09. 

2  Dent.  Arch.  f.  klin.  Med.,  1907,  LXXXIX,  547. 

3  Deut.  med.  Wochenschr.,  190(),  XXXI 1,  009. 
•»  Deut.  med.  Wochenschr.,  1900,  XXXII,  788. 
5  Journ.  Exper.  Med.,  1908,  X,  141. 

«  Ann.  de  I'iustit.  Pasteur,  1910,  XXIV,  96. 
28 


434 


THE  DISEASES  OF  CHILDREN 


which  have  been  repeatedly  inoculated  with  cultures  of  meningococcus. 
After  20  c.c.  (0.68  fl.oz.)  or  more  of  the  exudate  have  been  removed  by- 
lumbar  puncture  the  serum,  previously  slightly  warmed,  is  injected 
through  the  needle,  which  has  been  left  in  position.  It  may  be  given 
through  a  funnel  and  rubber  tube,  allowing  it  to  enter  by  gravity,  or 
a  piston  syringe  may  be  used  cautiously.  The  injection  should  always 
be  made  very  slowly.  The  amount  injected  should  always  be  less  than 
that  of  the  exudate  removed,  in  order  to  avoid  increasing  the  intracranial 
pressure.     Elevation   of  the  hips   favors   the   flow  of  the  serum  to  the 

diseased  region.  The  initial  dose  should  be 
10  to  15  c.c.  (0.34  to  52  fl.oz.)  for  infants  and 
not  over  30  c.c.  (1.014  fl.oz.)  for  older  chil- 
dren. The  injection  should  be  made  every 
24  hours,  sometimes  of  tener,  during  3  or  4 
days  or  more,  beginning  as  early  in  the 
course  of  the  attack  as  possible.  The  good 
results  are  sometimes  immediate  and  sur- 
prising. The  temperature  in  such  cases  may 
fall  several  degrees,  the  mental  symptoms 
are  greatly  ameliorated,  and  the  number  of 
neutrophiles  in  the  spinal  fluid  is  much  re- 
duced, and  of  the  meningococci  likewise. 
In  most  cases,  however,  even  where  there  is 
reason  to  believe  that  the  serum  is  exerting 
a  beneficial  action,  there  is,  in  my  experience, 
no  immediate  decided  effect  upon  the  tem- 
perature discoverable.  The  treatment  ap- 
pears to  produce  also  a  diminished  tendency 
to  the  development  of  sequels.  When  no 
fluid  can  be  obtained  by  lumbar  puncture, 
the  serum,  in  the  case  of  infants,  may  be  in- 
jected into  the  lateral  ventricles  after  with- 
drawing exudate  from  this  region. 

As  a  rule  the  injection  if  properly  made 
is  without  unfavorable  results;  but  occasion- 
ally a  considerable  degree  of  prostration 
follows,  and  sometimes  the  symptoms  be- 
come alarming,  chiefly  in  the  line  of  respira- 
tory failure.  Occasionally  it  has  been  neces- 
sary to  employ  artificial  respiration.  Some- 
times, too,  there  is  a  decided  reaction  with 
increased  restlessness,  nervousness,  and  rise  of  temperature  after  in- 
jection (Fig.  126,  and  history,  Fig.  117,  p.  424).  Consequently  a  care- 
ful continued  observation  of  the  state  of  the  respiration  and  the  general 
condition  of  the  patient  should  be  maintained  during  the  procedure  and 
after  it.  On  the  ground  that  the  disease  is  in  some  cases  primarily  a 
sepsis  the  administration  of  the  serum  intravenously  has  been  recom- 
mended, and  has  been  done  with  good  results  (Her rick. ^) 

As  regards  the  general  effect  of  the  serum  treatment  upon  prognosis, 
Flexner^  found  that  whereas  the  usual  mortality  in  various  parts  of  the 
world  had  reached  as  high  as  70  per  cent.,  in  1294  cases  receiving  this 
treatment  it  had  been  reduced  to  30.9  per  cent.  The  period  of  the 
disease  at  which  the  treatment  is  commenced  is  also  of  influence.     Of 

1  Jour.  Amer.  Med.  Asoc,  1918,  LXXI,  612. 

2  Journ.  Exper.  Med.,  1913,  XVII,  553. 


OAT  or  MONTH 

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Fig.  12  6  . — Cerebrospinal 
Fever,  with  Rise  of  Tempera- 
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Frank  F.,  2  years  old.  Chart 
shows  rise  of  temperature  which 
sometimes  occurs  after  serum- 
treatment.     Children's  Hospital. 


CEREBROSPINAL  FEVER 


435 


Flexner's  series  it  was  begun  in  199  in  the  first  3  days,  with  a  resulting 
mortahty  of  but  18.1  per  cent.  It  is  particularly  in  infancy  that  the 
good  results  are  seen.  Previously  nearly  all  of  this  age  died,  especially 
subjects  under  1  year  old,  whereas  in  129  of  Flexner's  cases  in  the  1st 
year  the  mortality  equalled  49.6  per  cent.  Between  5  and  10  years  of 
age  there  were  218  cases  with  a  mortality  of  15.1  per  cent.  That  serum- 
treatment  is  so  efficacious  in  some  instances  and  of  so  little  value  in 
others  depends  doubtless  in  part  upon  the  severity  of  the  infection  in 


Fig    127.    -Skui-m  Hash  i.v  C'KULijuoai'i.xAL  Fever. 
Child   of  3   years   in  the  Children's  Ward  of   the  University  Hospital,' Philadelphia. 
Urticarial  eruption  appeared  on  the  4th  day  after  the  first  intraspinal  injection  of  serum ; 
lasted  4  days.     Photograph  shows  widespread  eruption  over  the  face  and  body. 

the  individual  case,  and  in  part  probably  upon  the  strain  of  the  meningo- 
coccus, to  which  reference  has  been  made  (p.  417).  If  the  serum  con- 
tains a  strain  which  is  not  the  one  operative  in  the  case,  no  benefit  can, 
of  course,  be  expected. 

After  the  acute  stage  of  the  disease  is  over  little  benefit  is  to  be  ex- 
pected from  serum-treatment.  Nevertheless  it  should  by  all  means 
be  tried,  as  occasionally  good  results  follow.  To  avoid  mistakes  in 
diagnosis  it  must  be  rememb(>red  that  the  injection  of  serum  is  naturally 
capable  of  producing  the  same  symptoms,  including  the  cutaneous  erup- 
tion, which  occur  from  the  injection  of  antidiphtheritic  serum  (Fig.  127). 


436  THE  DISEASES  OF  CHILDREN 

CHAPTER  XI 
ERYSIPELAS 

Although  it  could  well  be  classified  as  a  form  of  sepsis,  erysipelas  has 
such  distinct  peculiarities  that  it  deserves  separate  consideration.  At 
one  time  a  greatly  dreaded  affection,  especially  in  hospital  practice, 
better  sanitary  methods  have  diminished  its  frequency  very  greatly. 

Etiology. — The  disease  is  widespread,  cUmate  and  locality  having 
no  influence  upon  it.  It  appears  to  be  more  common  in  the  cold  season 
of  the  year  and  particularly  in  spring.  Although  often  occurring  in  epi- 
demics, and  reappearing  with  especial  frequency  in  certain  localities, 
such  as  old  hospitals  not  well  cared  for  and  in  infant  asylums,  sporadic 
cases  sometimes  develop  in  institutions  under  the  best  hygienic 
regulations. 

Age  offers  no  protection,  yet  the  disease  appears  to  be  more  frequent 
at  certain  periods  of  life.  In  1568  cases  studied  by  Roger,  ^  27  occurred 
in  the  first  2  years  of  life;  6  at  from  2  to  5  years  inclusive;  60  at  from  6  to 
14  years;  189  at  from  15  to  20  years,  and  239  at  from  21  to  25  years. 
In  rare  instances  it  has  been  acquired  before  birth.  There  is  undoubtedly 
an  individual  susceptibility,  some  persons  being  particularly  liable  to  it, 
and  an  inheritance  of  this  susceptibility  seems  certainly  possible.  By 
far  the  most  important  predisposing  factor  is  the  presence  of  a  wound. 
Consequently  infants  with  an  umbilical  wound,  eczematous  areas, 
pustules  of  varicella,  and  the  like,  or  those  who  have  been  recently  cir- 
cumcised or  vaccinated,  are  especially  predisposed.  Sometimes  the 
portal  of  entry  is  the  mucous  membrane,  whence  the  disease  spreads 
to  the  skin;  yet  erysipelas  often  develops  without  the  slighest  abrasion 
being  discoverable  anywhere.  That  there  are  not  more  individuals  with 
wounds  attacked  indicates  the  lack  of  susceptibility  in  the  majority 
of  them. 

Erysipelas  is  clearly  an  infectious  disease,  the  germ  being  transmitted 
by  direct  contact  or  by  clothing  and  the  like,  or  by  means  of  a  third 
person.  It  is  not  diffused  by  the  ah'  to  any  extent.  The  specific  geivn, 
the  streptococcus  erysipelatis,  first  isolated  and  identified  by  Fehleisen^ 
has  been  found  to  be  a  form  of  the  streptococcus  pyogenes.  Its  vitality 
is  not  great,  since  it  lives  in  cultures  not  longer  than  2  to  3  weeks. 
Occasionally  other  germs  than  the  streptococcus  appear  able  to  produce 
the  disease. 

Pathological  Anatomy. — The  affected  skin  exhibits  post-mortem 
an  exudation  of  serum  and  of  lymphoid  cells  in  the  cutis  and  subcutaneous 
tissue,  with  dilated  and  engorged  blood-vessels,  and  with  very  numerous 
cocci  in  the  lymph  channels ;  these  being  most  numerous  in  the  region 
last  involved.  Sometimes  large  bullae  containing  serum,  are  found. 
In  the  most  severe  cases  evidences  of  suppuration  are  observed  in  the 
subcutaneous  connective  tissue.  Often  alterations  are  present  in  other 
parts  of  the  body,  among  these  being  enlargement  of  the  spleen,  parenchy- 
matous changes  in  the  liver  and  kidneys,  infarcts  in  the  lungs,  kidneys 
and  spleen,  septic  endopericarditis  and  pleuritis,  lymphatic  swelling, 
peritonitis,  and  occasionally  meningitis. 

1  Arch.  gen.  de  med.,  1901,  CLXXXVIII,  5. 

2  Deutsch.  Zeitschr.  f.  Chir.,  1882,  XVI,  391. 


ERYSIPELAS 


437 


Symptoms.  Incubation. — The  period,  of  incubation  is  generally 
short,  from  15  to  60  hours  as  proven  by  the  inoculation  experiments  of 
Fehleisen. 

Symptoms  of  the  Attack. — Initial  symptoms  may  be  absent,  or 
consist  of  chilliness,  coldness  of  the  extremities,  restlessness,  prostration, 
vomiting,  high  fever,  and  occasionall}^  convulsions.  Simultaneously, 
or  nearly  so,  redness,  swelling  and  tenderness  of  the  skin  develop  in  the 
affected  area.  Roger's  statistics^  show  that  the  face  is  much  most 
frequently  the  starting  point.  This  was  true  of  83  per  cent,  of  the  cases  at 
all  ages.  In  66  children  of  from  2  to  15  years  the  disease  began  in  the  lower 
extremities  in  but  4  instances.  The  redness  exhibits  the  uniform  flush 
of  a  dermatitis,  which  it  is;  unlike  that  of  scarlet  fever.     Its  border 


Fig.  128. — Erysipel.\s  Beginning  on  the  Neck. 
Child  of  7  weeks,  in  the  Children's  Ward  of  the  University  Hospital  in  Philadelphia, 
suffering  from  chronic  gastrointestinal  disturbance.     Improved  slowly  during  2  months. 
Then  developed  fever  and  eruption  of  erysipelas  on  the  neck,  with  large  bullae.     Died  after 
an  illness  of  less  than  a  week. 

is  sharply  defined,  elevated,  and  either  clean  cut  or  with  irregular  pro- 
jections jutting  out  here  and  there  into  the  healthy  skin.  When  the 
process  is  severe  vesicles  or  bullae  form  upon  the  affected  skin  (Fig.  128). 
Within  2  to  3  days  the  inflammation  begins  to  disappear  in  the  part 
first  involved,  and  desquamation  follows,  usually  in  fine  scales,  but 
coarser  and  in  larger  pieces  if  vesicles  have  been  present.  In  the  mean- 
time the  border  of  the  infiltrated  region  has  extended  more  or  less  rapidly, 
sometimes  a  considerable  area  becoming  involved  in  a  few  hours,  and 
sometimes  the  advance  being  very  slow. 

The  manner  of  the  spreading  and  the  degree  of  swelling  depend  largely 
upon  the  locality.  Where  the  skin  is  firndy  adherent  to  underlying 
structures,  as  at  the  chin,  the  patolhc  and  the  condyles,  the  disease 
often  passes  around,  leaving  these  areas  unaffected.  Where  the  tissue 
is  loose,  as  at  the  genitals  and  the  eyelids,  the  edema  is  great.     When 

^  Loc.  cit. 


438  THE  DISEASES  OF  CHILDREN 

the  disease  starts  at  the  nose  this  organ  swells  rapidly  and  the  rash  gener- 
ally quickly  spreads  to  the  cheeks  in  the  well-known  butterfly  form. 
It  often  stops  here,  but  it  may  involve  the  eyelids,  closing  them  for 
days,  or  may  extend  over  one  or  both  sides  of  the  face  and  to  the  ears 
(Fig.  129).  The  whole  scalp  may  be  finally  involved.  Under  such 
circumstances  the  head  and  face  seem  twice  their  natural  size  and  the 
child  is  entirely  unrecognizable.  The  inflammation  may  cease  here, 
or  may  spread  to  the  body.  Developing  about  a  vaccine  pustule  or 
other  lesion  on  the  arm  or  leg,  it  may  remain  confined  to  this  locality, 
or  may  extend  rapidly  over  the  whole  limb  and  thence  to  other  parts, 
but  not  so  often  to  the  head  as  elsewhere.  In  some  cases  the  disease 
appears  to  start  on  the  mucous  membrane  of  the  nose,  throat,  or  mouth 
and  spread  to  the  face,  the  first  symptoms  being  a  severe  angina  or 
coryza.  In  other  cases  it  first  attacks  the  mucous  membrane  of  the 
vulva  and  extends  to  the  thighs  and  other  regions.  ^  -'^'^^     -^^ 


Fig.   129. — Erysipelas  with  Great  Swelling  of  the  Head. 
Child  of  14  months,  in  the  Children's  Hospital  of  Philadelphia.     Disease  began  in  the 
face,  involved  the  head,  closing  the  eyes,  thence  spread  to  the  rest  of  the  body.     Death  9 
days  after  the  onset. 

The  tendency  of  the  rash  to  spread  varies  greatly.  It  may  be  very 
slight,  the  dermatitis  reaching  but  little  beyond  the  point  of  original 
appearance.  On  the  other  hand  the  eruption  may  wander  more  or  less 
rapidly  over  the  whole  body  {erysipelas  migrams) ,  returning  and  attacking 
again  parts  from  which  it  had  disappeared  but  a  short  time  before. 
This  spreading  is  often  in  the  form  of  repeated  short  advances,with  inter- 
missions during  which  improvement  in  the  general  symptoms  leads  to 
the  false  hope  that  the  attack  is  over. 

Symptoms  Attending  the  Eruption. — The  temperature  as  a  rule 
rises  very  rapidly  and  remains  at  104°F.  (40°C'.)  or  more,  with  but  slight 
morning  fall,  as  long  as  the  spread  of  the  rash  is  uninterrupted  (Fig. 
130).  In  very  mild  cases  fever  may  be  entirely  absent  or  undiscovered. 
It  generally  is  in  proportion  to  the  severity  of  the  cutaneous  manifesta- 
tions. Each  temporary  cessation  of  the  spreading  of  the  disease,  with 
subsequent  recrudescence,  usually  is  indicated  by  a  fall  of  temperature 
followed  by  a  rise  (Fig.  131).     An  intermittent  extension  has  therefore 


ERYSIPELAS 


439 


an  intermittent  temperature;  a  steady  spread,  a  temperature  more 
continuously  elevated.  The  lymphatic  glands  in  the  neighborhood  of  the 
dermatitis  are  nearly  always  inflamed.  In  severe  cases  the  appetite  is 
poor,  the  tongue  dry,  the  pulse  weak  and  respiration  sometimes  dyspneic. 
Restlessness,  delirium  or  sopor  not  infrequently  occur.  The  blood  shows 
a  leucocvtosis  most  marked  in  the  severe  cases.     Transient  albuminuria 


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Fig.  130. — Erysipelas,  Average  Case. 
Elsie  S.,   aged  Z\i  years.     Aug.  3,  4th   day  of   disease,  eruption  spreading  over  left 
leg;  Aug.  5,  involving  foot;  Aug.  6,  no  extension;  Aug.  8,  rapid  extension  to  buttock  with 
increase  of  fever;  Aug.  13,  fresh  extension,  involving  right  leg  and  trunk;  Aug.  14,  develop- 
ment of  bullae,  with  increase  of  fever;  Aug.  17,  convalescing. 

Fig.   131. — Mild  Erysipelas  with  Recrudescence  of  Fever  Attending  Extension 

OF  Rash. 
Edith  S.,  aged  7  years.     Apr.  22,  red  flush  right  cheek,  extending  over  nose;  Apr.  23, 
large  blebs  on  right  cheek,  eye  nearly  closed;  Apr.  24,  extension  to  left  cheek  with  renewed 
fever;  Apr.  26,  improving. 

is  occasionally  present.  The  complex  of  symptoms  varies,  being  often 
influenced  by  the  complications  which  are  prone  to  occur  (Figs.  132  and 
133).  J  , 

The  (luraiion  of  the  disease  is  extremely  variable.  As  already  stated 
the  height  of  the  affection  in  any  one  spot  is  reached  in  2  to  3  days, 
and  recovery  in  that  region  is  rapid.  An  average  duration  of  the  entire 
attack  is  7  to  9  days  but  it  may  last  less  than  this  or  often  much  longer, 
and  in  cases  of  erysipelas  migrans  may  continue  occasionally  even  tor 

months.  •  n      i 

Erysipelas  in  Early  Infancy.  -This  condition,  ami  especially  that  denom- 
inated Kn/sipclas  neonatorum,  differs  somewhat  from  the  disease  as  seen 
later.     The  regions  first  attacked  are  oftenest  the  umbilicus,  viilv.i.  :iiuis. 


440 


THE  DISEASES  OF  CHILDREN 


and  the  lesions  of  circumcision  or  vaccination,  rather  than  the  head.  The 
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When  fever  develops  the  spleen  enlarges,  vomiting  and  diarrhea  are 
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rapid  septic  symptoms  appear,  the  pulse  is  very  rapid  and  weak,  food  is 
refused,  collapse  supervenes,  convulsions  may  occur,  and  death  may 
follow  within  a  week  or  even  a  day  or  two  from  the  onset.  There  is  a 
decided  tendency  for  the  disease  to  assume  the  wandering  type  if  the  in- 
fant lives  long  enough.  The  eruption  differs  little  from  that  seen  later 
in  life,  except  that  the  swelling  is  liable  to  be  greater  and  more  tense, 
the  redness  less  intense,  the  boundary  less  raised  and  desquamation  more 
liable  to  occur.  The  cases  which  recover  generally  develop  cutaneous 
abscesses. 


ERYSIPELAS 


441 


Complications  and  Sequels.^ — ^Suppuration  in  the  subcutaneous 
tissues  is  not  infrequent  (Fig.  ]32),  and  necrosis  of  portions  of  the  skin 
have  been  reported.  Bronchitis,  pneumonia  (Fig.  133),  peritonitis  and 
endocarditis  may  occur,  and  edema  of  the  larynx  sometimes  develops. 
^Meningitis  is  an  occasional  complication,  although  many  subjects  exhibit- 
ing its  symptoms  show  no  such  lesion  at  autopsy.  Nephritis  is  not  com- 
mon.    Suppuration  of  joints  or  of  lymphatic  glands  is  sometimes  seen. 

Erysipelas  may  occur  in  combination  with  many  other  diseased  con- 
ditions, especially,  as  indicated,  with  wounds.     It  may  be  a  complica- 


FiG.   133.- — Erysipelas,  Severe  Case.     Bronchopneumonia. 
Adelaide  C,  aged  7  months.     Feb.  7,  swelling  of  left  labia;  Feb.  14,  involvement  of 
right  labia;  Feb.  16,  bronchopneumonia;  Feb.  20,  rash  has  been  steadilj'-  spreading,  involv- 
ing abdomen  and  lower  extremities;  severe  toxic  state;  death. 

tion  of  other  infectious  disorders,  as  scarlatina,  malaria,  typhoid  fever, 
cerebrospinal  fever  and  diphtheria.  In  the  last  three  it  generally  results 
from  the  development  of  a  bed  sore  or  other  open  wound. 

Relapse  and  Recurrence. — In  addition  to  the  frequent  recru- 
desccnces»with  pseudo-crises  so  characteristic  of  the  disease,  true  relapse 
may  show  itself  after  several  days  or  even  a  few  weeks.  It  probably 
owes  its  origin  to  the  remaining  of  small  infiltrated,  infected  foci  in  the 
skin.     The  relapse  may  be  repeated  a  number  of  times. 

Recurrence  in  the  sense  of  a  new  infection  is  more  common  than  relapse. 
In  fact,  one  attack  creates  abfiolutely  no  immunity,  but  rather  seems  to 
predispose  to  later  ones.  Frequent  recurrence  is  liable  to  result  in 
permanent  thickening  of  the  affected  areas,  especially  the  scrotum  and  the 
eyelids. 

Prognosis. — One  of  the  most  important  factors  is  age.  In  the 
new  born  erysipelas  is  almost  ahvays  fatal  and  at  any  period  of  infancy  it 
is  serious,  especially  in  the  first  2  or  3  months  of  life.     In  childhood 


442  THE  DISEASES  OF  CHILDREN 

recovery  generally  takes  place  if  the  disease  is  uncomplicated  and  of 
moderate  extent. 

The  situation  involved  is  of  importance  as  well.  The  prognosis  is 
prone  to  be  worse  if  the  head  is  attacked.  Wandering  erysipelas  has  a 
graver  prognosis  than  the  more  limited  form,  since  its  long  duration  tends 
to  produce  exhaustion. 

Among  unfavorable  symptoms  are  very  high  temperature,  weakness  of 
the  heart,  and  cerebral  symptoms.  All  complications  increase  the  gravity 
of  the  case  and  death  may  follow  pneumonia  and  sometimes  peritonitis, 
meningitis,  and  involvement  of  the  kidneys. 

Diagnosis. — This  rests  upon  the  combination  of  constitutional 
symptoms  with  a  dermatitis  of  peculiar  nature,  often  with  vesicles  and 
with  marked  tendency  to  extension.  The  latter  features  and  the  sharply 
defined  border  differentiate  it  from  other  forms  of  dermatitis.  The  rash 
of  scarlet  fever  is  distinguished  by  its  punctiform  character.  Deep- 
seated  phlegmonous  inflammation  lacks  the  characteristic  border,  as 
does  also  lymphangitis,  which  has,  too,  an  entirely  different  outline,  since 
it  follows  the  course  of  the  lymphatic  vessels.  Erythema  infectiosum, 
while  having  a  distribution  and  color  upon  the  face  suggesting  erysipelas, 
lacks  the  sharp  outline  and  the  infiltration,  and  exhibits  a  morbiliform 
rash  on  the  trunk  and  limbs. 

Treatment.  Prophylaxis. — Especial  care  should  be  taken  to  insure 
asepsis  of  the  umbilical  wound  of  the  new  born.  Infants  should  be  re- 
moved from  their  mothers  if  the  latter  are  suffering  from  puerperal 
fever.  All  possible  precautions  should  be  employed  in  performing  vacci- 
nation and  circumcision,  and  all  children  with  open  wounds  should  be 
carefully  separated  from  patients  with  erysipelas. 

Treatment  of  the  Attack. — So  far  as  drugs  are  concerned,  although  the 
number  tried  is  very  great,  none  can  be  called  specific.  The  internal  ad- 
ministration of  tincture  of  the  chloride  of  iron  in  large  doses  has  long  been 
a  favorite.  There  appears  to  be  some  evidence  that  it  does  good,  and  at 
any  rate  it  can  be  said  for  it  that  it  can  do  no  harm.  Quinine  and 
salicylic  acid  in  full  doses  are  each  favorite  remedies  with  many.  Locally 
the  remedies  most  in  favor  are  petrolatum,  ointment  of  ichthyol  (5  to 
15  per  cent,  or  stronger);  ointment  or  glycerin-solution  of  resorcin  (30  per 
cent,  or  more);  powders  of  iodoform,  oxide  of  zinc,  or  starch  and  salicylic 
acid;  compresses  or  solutions  of  bichloride  of  mercury  (1  :2000),  boric 
acid,  lead  water  and  laudanum,  and  alcohol  and  water.  Of  all  of  these 
the  application  of  ichthyol  ointment  or  of  ichthyol  collodion  (10  per  cent, 
or  more)  is  perhaps  one  of  the  most  popular,  and  the  course  of  the  disease 
often  appears  to  be  much  abbreviated  by  the  treatment.  Hypodermic 
injection  of  anti-streptococcic  serum  or  of  autogenous  vaccines  has  been 
employed,  but  the  results  have  been  inconclusive.  I  have  seen  prompt 
recovery  follow  their  use,  but  could  not  determine  that  this  was  because 
of  it.  Erdman's^  experience  in  800  cases  of  erysipelas  did  not  show  any 
shortening  of  the  attack  in  95  instances  in  which  vaccines  had  been  used. 

Other  treatment  is  symptomatic.  The  general  strength,  and  espe- 
cially that  of  the  heart,  may  require  alcoholic  stimulants  and  digitalis. 
Suitable  nourishment  must  be  given;  excessive  temperature  may  require 
warm  or  cool  bathing;  threatening  nervous  symptoms  may  be  treated 
hydropathically  or  may  need  bromides,  antipyrine,  or  occasionally,  opium. 
Complications  call  for  treatment  appropriate  to  them. 

1  Journ.  Amer.  Med.  Assoc,  1913,  LXI,  2048. 


DIPHTHERIA  443 

CHAPTER  XII 
DIPHTHERIA 

History.^ — Recognition  of  an  infectious  epidemic  disorder  char- 
acterized by  the  development  of  a  membrane-hke  coating  generally  situa- 
ted in  the  fauces,  nose  or  larj'nx,  appears  to  date  from  very  early  times. 
Perhaps  the  first  clear  account  was  given  by  Aretaeus^  in  the  1st  century. 
It  ravaged  Europe  in  the  16th  and  17th  centuries  and  was  described  in 
America  by  Douglas^  in  1736  and  very  completely  by  Bard^  in  1771. 
Variously  designated,  it  was  first  called  ''Diphtheritis"  {bupdepa  =  a 
membrane  or  skin)  by  Bretonneau.*  Since  the  discovery  of  the  specific 
bacillus  by  Klebs  the  term  diphtheria  is  properly  applied  only  to  the 
disease  dependent  upon  this  germ.  The  other  pseudomembranous 
affections  of  the  throat  should  be  entitled  pseudodiphtheria. 

Etiology.  Predisposing  Causes. — The  disease  is  of  very  frequent 
occurrence,  and  prevails  in  all  climates  and  all  civilized  countries  without 
regard  to  locality,  although  perhaps  most  common  in  cold,  damp  regions 
and  in  the  cooler  months  of  the  year.  Humiditj'-  is  a  decided  factor 
through  its  influence  in  favoring  catarrhal  affections,  any  acute  or  chronic 
catarrhal  disorder  of  the  mucous  membrane  of  the  nose  or  throat,  as  also 
the  presence  of  adenoids  and  of  enlarged  tonsils,  rendering  the  subject 
more  susceptible.  Poor  sanitation  or  any  sort,  and  impaired  health  in 
general,  increase  the  tendency  to  the  disease  by  diminishing  the  resisting 
powers.  For  this  reason,  certain  other  infectious  disorders,  especially 
scarlet  fever  and  measles,  as  well  as  influenza  and  pertussis,  augment  the 
susceptibility. 

Age  is  an  important  predisposing  factor.  The  disease  is  most  fre- 
quent up  to  10  years,  and  especially  from  1  to  5  years  of  age.  Of  9011 
cases  admitted  to  the  Philadelphia  Hospital  for  Contagious  Diseases 
(Welch  and  Schamberg,)'  4076  were  from  1  to  5  j^ears  old.  It  is  less 
common  in  the  1st  year  and  especially  in  the  first  6  months.  In  2600 
cases  reported  by  Rolleston,^  there  were  but  20  occurring  in  the  1st  year; 
and  in  2711  cases  in  children  Baginsky^  found  only  15  (0.15)  per  cent.) 
under  6  months  of  age.  Yet  new-born  children  are  occasionally  attacked 
(Jacobi)*  (Riesman,'*  infant  of  11  days;  Stimson,^*^  10  days;  primary  nasal). 
There  exists  often  a  very  striking  family  predisposition,  but  apart  from 
this  the  indwidual  susceptibility  is  not  very  great  and  the  disease  much 
oftener  limits  itself  to  a  single  child  in  a  family  than  is  the  case  in  some 
other  infectious  diseases,  notably  measles.  This  immunity  (see  p.  460) 
may  be  overcome  through  various  influences,  and  as  a  result  the  disease 
may  appear  at  times  in  extensive  epidemics  in  some  years,  with  but  few 
cases  in  others.  In  lai-ge  cities  it  is  endemic  to  a  varying  degree,  and  it 
may  develop  sporadicalh'  in  localities  where  its  origin  cannot  be  traced. 

^  De  causis  et  signis  acut.  niorb.  L.  I,  Cap.  9.  Ref.  Baginsky  in  Nothnagel's 
Handb.  d.  spec.  Path.  u.  Thcrap.  Diphtheria. 

-  Pract.  Hist,  of  a  new  erupt,  niiliarial  fever  with  angina  ulcusculosa,  Bost.,  1736. 
Ref.  Baginsky,  loc.  oil.,  6. 

«  Transac.  Amer.  Philosoph.  Soc,  1779,  I,  338. 

••  Des  inflam.  .spec,  des  tissu  muqueux  etc.,  Paris,  1826.     Ref.  Bagin.>^ky,  he.  cit. 

*  Acute  Contagious  Diseases,  1905,  Oil. 

6  Amer.  Jour.  Dis.  Child.,  1916,  Xll,  47. 

I AfiC     of,        ^^ 

8  20th  Cent.  Pract.  Med.,  XVII,  77,  Article  Diphtheria. 

9  Phila.  Med.  Jour.,  1898,  March  5. 

1"  New  York  Med.  Jour.,  1907,  Dec.  14. 


444  THE  DISEASES  OF  CHILDREN 

Exciting  Cause. — This  is  now  well  recognized  to  be  a  specific  bacillus 
first  recognized  by  Klebs^  in  1883,  and  shown  to  be  the  sole  cause  of  the 
disease  by  Loeffler^  in  1884.  Roux  and  Yersin^  in  1888  proved  that  this 
germ  was  capable  of  occasioning  in  animals  the  same  paralytic  conditions 
as  are  seen  in  man,  and  demonstrated  the  production  by  it  of  a  poisonous 
substance  upon  which  the  various  symptoms  of  the  disease  depend. 
All  later  observations  confirm  the  etiological  relationship  of  the  germ. 

The  microorganism  is  a  non-motile,  non-spore-bearing  Gram-positive 
bacillus,  averaging  about  the  length  of  the  tubercle  bacillus  but  thicker. 
It  is  straight  or  slightly  curved  and  often  somewhat  club-shaped  at  the 
ends.  It  has  the  characteristic  peculiarity  of  varying  greatly  in  size, 
form  and  staining  qualities,  depending  on  its  age  and  on  the  culture- 
medium  employed,  and  stains  well  with  alkaline  methylene  blue  as  recom- 
mended by  Loeffler,  but  always  with  unstained  spots,  the  club-shaped 
ends  being  most  intensely  colored. 

Life  History. — -The  bacillus  is  readily  killed  by  a  temperature  of  58°C 
(136.4°F.)  but  is  not  affected  bj^  cold.  Under  normal  conditions  it  is 
very  tenacious  of  life.  In  the  great  majority  of  cases  it  disappears 
from  the  throat  in  2  to  4  weeks  from  the  beginning  of  the  disease,  but  it 
may  sometimes  persist  for  weeks  or  months  in  a  virulent  form  in  the 
throat  or  nose  of  those  who  have  passed  through  an  attack  or  who  have 
merely  been  exposed,  or  it  may  live  long  in  various  objects  entirely  apart 
from  the  body.  Abel^  found  it  living  for  over  6  months  on  toys  which  had 
been  kept  in  a  dark  place,  Klein^  for  18  months  in  cultures,  Le  Gendre  and 
Pochon*^  for  15  months  in  the  throat,  and  Valagussa^  living  but  completely 
dry  for  26  months.  It  occurs  sometimes  in  the  secretion  from  purulent 
otitis  media  or  may  occasionally  be  found  in  the  tissues  of  the  body  or 
the  blood  and  the  urine.  Thus  in  209  fatal  cases  Councilman,  Mallory 
and  Pearce^  discovered  it  in  the  heart's  blood  12  times,  in  the  liver  42 
times,  and  in  the  spleen  26  times;  frequently  associated  with  the  strep- 
tococcus, less  often  with  the  staphylococcus  or  the  pneumococcus. 
Sommerfeld^  discovered  it  in  the  blood  in  42  out  of  320  cases  (13.1 
per  cent.).  It  has  also  been  found  in  the  lungs,  bone-marrow,  kidneys 
and  lymphatic  glands.  The  diphtheria  germ  is,  however,  as  a  rule 
not  widely  distributed  in  the  body,  being  confined  in  most  cases  to  the 
pseudomembrane  and  the  surface  of  the  mucous  membrane. 

The  disease  is  primarily  a  local  one,  the  germs  being  deposited  and  grow- 
ing upon  a  mucous  membrane  which  was  not  in  a  healthy  condition. 
Some  abrasion,  although  slight,  is  necessary  as  the  original  nidus.  The 
symptoms  resulting  depend  chiefly  on  the  absorption  of  the  poisonous 
principle  produced  by  the  bacillus,  and  perhaps  partly  upon  the  action  of 
associated  germs  especially  the  streptococcus  pyogenes  and  the  staphy- 
lococcus pyogenes.  There  is  no  diphtheria  without  the  specific  germ, 
and  it  is  equally  true  that  the  mere  discovery  of  this  on  the  mucous  mem- 
brane does  not  indicate  the  presence  of  diphtheria. 

Diphtheria  bacilli  may  lose  their  virulence,  and  such  germs,  although 

1  Verhandl.  d.  Cong.  f.  inn.  Med.,  1883,  II,  139. 

2  Verhandl.  d.  Cong.  f.  inn.  Med.,  1884,  III,  156. 

3  Annales  de  I'institute  Pasteur,  1888,  II,  629. 
^  Centralbl.  f.  Bakt.,  1893,  XIV,  756. 

5  Centralbl.  f.  Bakt.,  1890,  VII,  492. 

«  Bull.  soc.  des  hop.,  1895,  XII,  815. 

'  Riv.  di  din.  pecUat.,  1909,  VII,  332. 

8  Bact.  and  Pathology  of  Diphtheria,  1901,  p.  16. 

3  Arch.  f.  Kinderh.,  1913,  LX-LXI,  698. 


DIPHTHERIA  445 

morphologically  and  in  reality  identical  with  the  virulent  ones,  are 
without  danger  to  those  acquiring  them.  As  a  rule,  the  more  virulent 
the  germ,  the  worse  the  attack  of  the  disease;  but  to  this  there  are  many 
exceptions,  and  the  mildest  cases  may  transmit  very  virulent  germs  and 
occasion  a  severe  attack  in  another  subject. 

Another  organism  has  been  described,  known  as  the  pseudo-diphtheria 
bacillus,  or  the  Hofmann-Wellenhof  ^  bacillus,  which  is  very  similar  to, 
but  not  identical  morphologically  and  culturally  with  that  of  diphtheria, 
and  is  not  capable  of  producing  the  disease.  Whether  this  is,  in  reahty, 
different  from  the  avirulent  Klebs-Loeffler's  bacillus,  or  only  a  variant, 
is  not  yet  positively  determined,  but  the  latter  seems  very  possible. 

Transmission. — The  disease  is  a  strictly  infectious  one  and  never 
develops  independently.  Indirect  transmission  is  much  the  least  fre- 
quent method  of  communicating  the  infection.  It  may  occur  through 
infected  milk,  or  occasionally  by  domestic  animals,  or  by  books,  toys, 
clothing  and  other  inanimate  objects.  In  the  large  majority  of  cases  the 
germs  are  communicated  directly,  either  from  an  unrecognized  case,  or 
by  a  convalescent,  or  by  a  healthy  person  who  has  never  had  diphtheria 
but  who  has  the  virulent  bacteria  present  in  the  throat  or  nose.  Such 
convalescents  and  health}^  persons  are  called  "carriers."  The  remark- 
able persistence  of  the  germs  on  the  mucous  membranes  of  convalescents 
or  of  healthy  persons  which  is  frequently  seen,  and  their  tenacity  of 
life,  account  for  cases  which  occur  sporadically  and  without  discov- 
erable source.  The  existence  of  mild  unrecognized  nasal  diphtheria  is 
a  very  fruitful  cause  of  dissemination  of  the  disease  in  schools,  hospitals, 
and  elsewhere.  Transmission  may  occur  from  the  beginning  of  the 
attack  or  even  before  any  symptoms  appear.  It  continues  possible  as 
long  as  the  bacilli  remain  virulent  in  the  carrier.  The  difficulty  in 
controlling  the  spread  of  the  disease  is  shown  by  the  investigations  of  the 
Massachusetts  Boards  of  Health-  according  to  which  at  least  from  1  to  2 
per  cent,  of  all  dwellers  in  cities  have  genuine  diphtheria  bacilli  on  the  mu- 
cous membrane  of  the  throat,  as  have  from  8  to  50  per  cent,  of  those  who 
have  been  in  any  way  exposed  to  the  disease.  Pennington^  found  that 
10  per  cent,  of  all  the  apparently  healthy  children  examined  in  the  public 
schools  of  Philadelphia  exhibited  diphtheria  bacilli,  non-virulent  in  about 
3=-^  of  the  cases,  von  Sholly*  discovered  the  germs  in  the  throats  of 
5.6  per  cent,  of  1000  healthy  school-children;  and  Schrammen^  in  (3.5  per 
cent,  of  704  school-children,  although  at  the  time  there  was  not  a  single 
case  of  diphtheria  in  the  schools  or  in  the  families  of  the  children. 

Pathological  Anatomy. — The  lesions  of  diphtheria  may  be  divided 
into  primary  and  secondarv.  The  primary  lesion  consists  in  the  pro- 
duction of  the  pseudo-membrane.  This  is  found  oftenest  upon  the  ton- 
sillar tissue  in  the  fauces  and  the  nasopharynx;  very  frequently  in 
addition  upon  the  phar3'nx,  uvula,  larynx,  trachea  and  bronchi;  less  often 
in  the  mouth,  vulva,  vagina,  middle  ear,  conjunctiva,  esophagus,  stomach 
and  intestine.  It  may  also  occur  occasionally  on  wounds,  as  upon  the 
penis  after  circumcision.  ]\Iacroscopicalh'  the  pseudo-membrane  is  a 
greyish-white  or  yellowish-white  substance,  tough  or  friable,  covering  a 

1  Wicn.  med.  Wochcnschr.,  1888,  XXXVIII.  60. 

2  Journ.  AI;iss.  Assoc.  Bojirds  of  Health,  1902,  .July.  Kef.,  Wolch  and  Schamberg, 
Acute  Contagious  Diseases,  1905,  019. 

»  Journ.  Infect.  Dis.,  1907.  IV,  .SO. 

*  Research  Lab.,  Dept.  of  Health,  New  York  Citv,  1905,  I,  SS;  Journ.  Infect.  Dis., 
1907   IV   337. 

» bentralbi.  f.  Bakt.,  Orig.,  1912-13,  LXVII,  423. 


446  THE  DISEASES  OF  CHILDREN 

smaller  or  larger  area.  In  places  it  can  be  removed  rather  readily,  but 
for  the  most  part  only  with  injury  to  the  tissues  beneath.  On  the  larynx 
it  is  firmly  adherent;  on  the  trachea  easily  detached.  In  severe  cases  it 
soon  assumes  a  dark-greenish  or  blackish  color  or  a  gangrenous  appearance. 
The  surrounding  tissue  is  deeply  congested. 

Microscopically  the  pseudomembrane  consists  of  a  degeneration  and 
necrosis  of  the  mucous  membrane  combined  with  an  inflammatory 
fibrinous  exudate  from  the  underlying  blood-vessels.  This  exudate  may 
be  in  granular  form,  but  oftener  appears  as  a  fine  network  which  includes 
in  its  meshes  leucocytes  and  degenerated  epithelial  cells  as  well  as  diph- 
theria bacilli  and  micrococci.  The  blood-vessels  and  connective  tissue 
beneath  the  pseudo-membrane  exhibit  thickening  and  hyaline  transforma- 
tion. The  diphtheria  bacilli  do  not  reach  the  lowest  layers  of  the 
exudate. 

A  distinct  pseudo-membrane  is  not  necessarily  present  in  diphtheria. 
Not  infrequently  there  appear  instead  merely  a  few  spots  of  yellowish, 
soft  secretion  in  the  crypts  of  the  tonsils  {diphtheritic  folliculitis) ,  while 
in  other  cases  only  a  catarrhal  condition  of  the  mucous  membrane  of  the 
throat  is  discoverable  (catarrhal  diphtheria).  Nevertheless,  even  in 
the  latter  condition,  the  characteristic  necrotic  changes  can  be  discovered 
in  the  superficial  cells. 

The  primary  lesion  of  diphtheria  possesses  little  importance  except 
when  in  the  larynx,  where  by  its  mechanical  interference  it  may 
cause  suffocation.  It  is  the  secondary  lesions  which  constitute  the  chief 
danger  of  the  disease.  These  are  the  widespread  degenerative  changes 
in  the  various  tissues  of  the  body,  the  result  of  the  action  of  the  powerful 
toxin  produced  by  the  diphtheria  bacillus  in  the  primary  lesions  and 
absorbed  and  distributed  by  the  blood  and  the  lymph.  Other  microbes 
present  in  the  pseudo-membrane  probably  aid  in  the  destructive  process, 
either  by  the  local  formation  of  toxins  and  the  subsequent  absorption 
of  these,  or  by  directly  entering  the  blood-vessels  and  producing  a  sep- 
ticemia ;  but  the  chief  danger  is  from  the  toxin  of  the  diphtheria  bacillus 
itself.  The  changes  consist  in  cellular  degeneration  in  all  the  organs. 
The  cervical,  bronchial,  and  mesenteric  lymphatic  glands  are  enlarged 
and  congested  and  show  leucocytic  infiltration  and  often  hemorrhages. 
Scattered  bronchopneumonic  areas  are  common,  found  in  over  one-half 
of  the  autopsies.  A  serous  or  sero-fibrinous  pleurisy  may  occur.  Small 
hemorrhages  may  be  present  in  the  skin,  pleura,  pericardium  and 
endocardium  and  beneath  the  capsule  of  the  liver  and  spleen.  The  car- 
diac muscle  suffers  degeneration  in  all  long-continued  fatal  cases.  The 
arteries  sometimes  exhibit  proliferation  in  the  endothelial  lining.  The 
spleen  is  increased  in  size,  soft,  and  dark-red;  its  follicles  enlarged,  cellular 
degeneration  prominent  and  hemorrhages  frequent.  The  kidneys  are 
larger  than  normal,  soft,  and  exhibit  changes  varying  from  simple 
degeneration  to  a  serious  degree  of  acute  nephritis,  there  being  no  type  of 
nephritis  peculiar  to  diphtheria  (Councilman,  Mallory  and  Pearce) .  ^  The 
interstitial  and  glomerular  forms  are  more  common  in  older  children  and 
in  long-continued  cases.  The  liver  is  slightly  enlarged  and  soft,  and  with 
necrotic  alteration  of  the  cells,  especially  in  the  interior  of  the  lobules. 
The  brain  and  spinal  cord  are  generally  little  altered.  Occasionally 
hemorrhages  or  a  moderate  fatty  degeneration  of  the  white  substance  is 
found.     The  cranial  and  spinal  nerves  exhibit  a  wide-spread  degenei'ation. 

1  Loc.  cit,  152. 


DIPHTHERIA  447 

Symptoms. — The  sjanptoms  of  diphtheria  vary  greatly  with  the 
locahty  affected,  as  well  as  with  the  intensity  of  the  intoxication  and  the 
complications  which  may  arise.  A  general  desci'iption  may  be  given  of  an 
average  case  of  the  commoner  form,  faucial  diphtheria,  as  illustrating 
the  ordinary  type  of  the  disease. 

Ordinary  Type.  Faucial  Diphtheria.  Incubation. — This  is  cer- 
tainly short,  varying  generally  from  1  to  4  days.  The  difficulty  in 
determining  it  exactly  depends  on  the  uncertainty  as  to  the  length  of 
time  the  bacilli  may  have  been  living  upon  the  mucous  membrane  without 
producing  local  or  general  infection. 

Invasion. — Symptoms  of  invasion  are  by  no  means  characteristic. 
Although  the  process  is  primarily  local,  the  first  clinical  manifestations 
noticed  are  more  constitutional  in  nature,  and  consist  in  chilliness,  slight 
fever,  and  loss  of  appetite;  sometimes  vomiting,  headache,  and  swelling 
of  the  cervical  glands,  and  occasionally  convulsions.  There  may  or  may 
not  be  complaint  of  sore  throat.  Inspection  shows  only  slight  coating 
of  the  tongue,  an  irregular  redness  and  swelling  of  one  or  both  tonsillar 
regions,  and  often  a  dark-red  coloring  of  the  mucous  membrane  of  the 
mouth. 

Symptoms  of  the  Attack.  — Within  24  hours,  however,  the  appearance 
is  more  characteristic  and  a  small  or  larger  yellowish-White  or  grayish- 
white  deposit  is  seen,  which  resembles  the  secretion  of  ordinary  follicular 
tonsillitis,  but  which  is  removable,  as  a  rule,  only  with  difficulty,  and 
appears  to  be  of  a  more  membrane-like  character.  New  membrane 
generally  forms  rapidly  after  such  removal.  Sometimes  the  early  ap- 
pearance of  the  deposit  is  more  gelatinous,  the  tonsil  seeming  to  be  cov- 
ered by  a  slightly  cloudy  mucilaginous  secretion. 

The  pseudo-membrane  spreads,  and,  if  limited  to  one  tonsil  at  the 
outset,  extends  to  the  other  in  from  2  to  5  days  and  often  to  the  uvula^ 
the  pillars  of  the  palate  and  the  soft  palate.  Its  color  has,  in  the  mean- 
time, become  a  dirty  grey,  the  odor  from  the  mouth  is  very  offensive, 
the  swelling  has  much  increased,  and  by  the  end  of  the  1st  week  the  entire 
fauces,  and  to  some  extent  the  pharynx,  may  be  covered  by  a  thick 
pseudo-membrane,  sometimes  almost  closing  the  throat,  the  nose  being 
also,  as  a  rule,  involved  to  some  extent.  (See  Nasal  Diphtheria,  p.  449.) 
The  degree  of  difficulty  in  swallowing,  and  the  amount  of  pain  in  the 
throat  are  very  variable  and  do  not  seem  to  bear  any  relation  to  the 
extent  of  the  inflammation. 

Meanwhile  the  constitutional  symptoms  increase  gradually  in  severity. 
The  cervical  glands  grow  larger,  generally  in  proportion  to  the  degree  of 
faucial  inflammation.  The  temperature  exhibits  no  exact  relation  to 
the  severity  of  the  symptoms  and  is  usually  about  101°  to  102°F.  (38.3° 
to  38.9°C.);  this  comparatively  low  degree  being  characteristic  of  the 
disease  (Fig.  134).  Sometimes,  however,  it  reaches  103°  or  104°F. 
(39.4°  to  40°C.)  or  more.  It  is  generally  highest  at  the  beginning  of 
the  attack  and  then  falls  somewhat  rapidly  or  slowly,  although  renewed 
rises  may  occur  as  the  disease  extends  to  new  regions  of  the  throat  or  as 
complications  develop.  Finally  it  reaches  normal  by  lysis  as  the  local 
symptoms  improve.  The  pulse  is  generally  weak  and  much  more  rapid 
than  is  in  accord  with  the  elevation  of  temperature,  and  the  blood- 
pressure  is  low.  This  disproportion  of  the  pulse-rate  to  the  temperature 
is  a  very  characteristic  symptom.  The  appetite  is  lost,  vomiting  is 
common,  constipation  is  the  rule.  The  urine  exhibits  albumin  in  the 
majority  of  cases,  although  generally  in  not  large  amount,  and  epithelial 


448 


THE  DISEASES  OF  CHILDREN 


cells  and  hyaline  casts  in  many  instances.     The  knee-jerks  are  often 
absent. 

The  hlood  shows  a  marked  polymorphonuclear  leucocytosis,  which 
increases  as  the  disease  advances  and  diminishes  during  convalescence. 
The  percentage  of  red  blood-corpuscles  and  of  hemoglobin  is  reduced  in 
all  severe  cases.  One  of  the  most  marked  symptoms  of  the  disease  is 
the  prostration  which  the  diphtheria  toxin  produces,  frequently  out  of 
all  proportion  to  the  severity  or  duration  of  the  other  symptoms.  In- 
creasing anemia,  loss  of  strength,  and  emaciation  may  be  decided.  Slight 
delirium  may  be  present  at  the  outset,  and  decided  apathy,  somnolence, 
or  irritability  later. 


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Fig.   134. — Tonsillar  and  Nasal  Diphtheria. 
Mary  K.,  aged  9  years.     Feb.  15,  onset  with  nausea,  vomiting,  sore  throat,  and  fever; 
Feb.  16,  tonsils  and  arches  covered,  nasal  discharge;  Feb.  18,  great  improvement;  Feb.  21, 
throat  clean.     Given  7500  units  antitoxin  on  16th;  7500  on  17th;  6000  on  18th;  5000  on 
19th.     Philadelphia  Hospital  for  Contagious  Diseases.     (Courtesy  of  Dr.  B.  F.  Royer.) 


About  the  end  of  the  1st  week,  or  frequently  not  until  later,  im- 
provement may  begin,  indicated  by  softening  and  separation  of  the 
pseudomembrane  and  the  gradual  amelioration  of  symptoms.  The 
disappearance  of  the  pseudomembrane  is  often  very  rapid,  especially 
under  serum-treatment.  Occasionally  deep  ulceration  of  the  mucous 
membrane  then  becomes  visible.  Very  often,  however,  the  local  and 
general  symptoms  continue  a  much  longer  time.  The  albuminuria  gen- 
erally persists  until  the  end  of  the  2d  or  3d  week. 

Convalescence  is  usually  slow  and  debility  long-continued.  Weak- 
ness of  the  heart  is  a  very  prominent  symptom  even  at  this  period  and 
death  may  occur  from  this  cause  after  the  membrane  has  nearly  or  quite 
disappeared  and  the  child  has  seemed  to  be  out  of  danger. 


DIPHTHERIA  449 

Very  frequently  associated  with  faucial  diphtheria  is  involvement  of 
the  nasopharynx.  This  decidedly  modifies  the  com'se  and  duration  of 
the  disease.  So  also  laryngeal  diphtheria  may  result  from  a  spread  of 
the  membrane  from  the  fauces  to  the  larynx.  The  symptoms  of  the  two 
affections  will  be  described  separately. 

Nasal  Diphtheria. — Nasal  diphtheria  may  be  primary  in  the  nose 
and  either  remain  limited  to  this  region  or  may  spread  to  the  naso- 
pharjmx,  the  throat,  or  the  larynx.  In  Other  cases  the  nasal  involvement 
is  secondary  to  the  affection  in  the  fauces  or  nasopharynx. 

Involvement  of  the  nose  and  nasopharynx  as  a  secondary  affection 
is  common  and  adds  to  the  severity  of  the  case  and  the  discomfort  of  the 
patient.  Respiration  through  the  nose  becomes  difficult  or  impossible, 
and  an  offensive  and  very  irritating  discharge  flows  from  the  nostrils, 
causing  excoriation  and  swelling  of  these  and  of  the  upper  lip.  Mem- 
brane may  be  seen  lining  the  anterior  nasal  passages,  and  epistaxis  is 
frequent.  Constitutional  symptoms  in  these  cases  are  generally  severe, 
and  the  duration  of  the  attack  is  prolonged.  The  disease  may  extend 
to  the  ear,  producing  a  purulent  otitis  media  as  a  complication  and 
resulting  in  a  still  longer  continuance  of  the  fever  and  of  other  symptoms. 

Primary  nasal  diphtheria  is  commonest  in  infants,  very  frequently 
remains  for  some  tune  undiscovered,  and  is  a  fertile  source  of  contagion. 
When  confined  to  this  region  either  no  general  symptoms  at  all  are 
noticed,  or  there  is  only  slight  fever  and  malaise.  The  child  appears  to 
have  merely  a  cold  in  the  head,  but  the  character  of  the  thin  and  very 
irritating  nasal  discharge  is  suspicious.  Examination  of  the  anterior 
nares  will  now  often  reveal  the  presence  of  pseudomembrane  and  of 
diphtheria  bacilli.  These  cases  run  a  somewhat  chronic  course.  In 
other  instances  the  affection  spreads  to  the  nasopharjmx  and  throat, 
and  the  constitutional  and  local  symptoms  are  decided.  Diphtheria 
primary  in  the  nasopharynx  is  generally  severe. 

Nasal  diphtheria,  either  primary  or  secondary,  is  a  common  form  of 
involvement.  In  1962  cases  of  diphtheria  in  the  Boston  City  Hospital, 
Burrows^  estimated  that  the  nose  exhibited  the  disease  in  about  40  per 
cent.,  and  in  1200  cases  of  faucial  diphtheria,  Rolleston^  found  involve- 
ment of  the  nose  in  41.6  per  cent. 

Laryngeal  Diphtheria. — This  may  properly  be  called  laryngo- 
tracheal diphtheria  since  the  pseudomembrane  may  involve  a  portion 
of  the  trachea  as  well,  or  even  extend  into  the  bronchi.  It  is  one  of  the 
most  dangerous  forms,  most  of  the  deaths  in  diphtheria  depending  upon 
this  cause.  The  vast  majority  of  cases  of  pseudomembranous  laryngi- 
tis, or  "true  croup,"  are  of  a  diphtheritic  nature,  and  almost  always  sec- 
ondarj'-  to  lesions  in  the  nose  or  the  throat,  although  the}'  often  appear 
primary  on  account  of  these  lesions  being  very  slight,  or  transitory  and 
overlooked.  Diphtheria  of  the  larynx  develops  about  the  4th  or  5th 
day  of  the  disease.  The  first  symptoms  are  hoarseness,  a  ringing  cough 
and  a  very  slightly  noisy  and  prolonged  respiration.  Apart  from  the 
influence  of  any  accompanying  pharyngeal  involvement  tiiore  is  little, 
if  any  constitutional  disturl)ance;  and  fever  may  or  may  not  be  present 
(Fig.  135).  The  symptoms  are,  in  fact,  local  and  are  those  of  laryngeal 
stenosis.  Generally  they  come  on  very  rapidly,  being  fully  developetl 
by  the  2d  day  of  laryngeal  involvement.     The  voice  becomes  very  hoarse, 

1  Amer.  Jour,  of  the  Med.  Sciences,  1901,  CXXI,  125. 

2  Report  Metropolitan  Asylums  Board,  1900. 

29 


450 


THE  DISEASES  OF  CHILDREN 


whispering  or  absent ;  the  cough  pecuharly  metalHc ;  and  dyspnea  severe, 
both  inspiration  and  expiration  being  prolonged  and  labored.  The  child 
has  an  extremely  anxious  expression;  is  restless  and  tossing;  often  sits 
upright  in  bed  with  head  thrown  back  and  draws  its  breath  onh^  with 
difficulty  and  with  the  aid  of  all  the  accessory  respiratory  muscles  and 
with  spreading  of  the  alse  of  the  nostrils.  There  is  retraction  of  the  epi- 
gastrium and  the  supraclavicular  and  suprasternal  spaces  and  a  lifting 
of  the  thorax  high  with  every  inspiration.  Cyanosis  is  marked  and  the 
skin  is  clammy.  Laryngoscopic  examination  reveals  edema  of  the 
mucous  and  sub-mucous  tissues  and  the  presence  of  pseudomembrane 
in  the  larjmx;  sometimes  one  predominating  and  sometimes  the  other. 


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Fig.  135. — Tonsillar  and  Laryngeal  Diphtheria. 
Joseph  S.,  aged  3  years.  Jan.  23,  onset  with  fever  and  croup;  Jan.  26,  both  tonsils 
covered,  complete  loss  of  voice,  some  stenosis;  Jan.  27,  less  pseudo-membrane  and  stenosis; 
Jan.  29,  throat  clean,  a  trifle  croupy.  Treatment,  Jan.  26,  10,000  units;  Jan.  27,  10,000 
units;  Jan.  28,  5000  units.  Philadelphia  Hospital  for  Contagious  Diseases.  {Courtesy  of 
Dr.  B.  F.  Royer.) 

The  symptoms  vary  from  time  to  time,  now  being  much  less  marked; 
now  increasing  to  the  point  of  impending  suffocation.  The  child  then 
becomes  livid,  grasping  at  its  throat  or  at  the  air  with  its  hands,  almost 
ceasing  to  breathe,  and  being  apparently  at  the  point  of  death.  This 
change  in  the  picture  depends  upon  the  varying  degree  of  edema  present. 
Occasionally  relief  is  afforded  by  the'  coughing  up  of  portions  of  pseu- 
domembrane, but  the  deposit  is  soon  reproduced  and  the  threatening 
symptoms  return.  Before  the  days  of  antitoxin-treatment  the  majority 
of  cases  grew  worse  with  varying  rapidity,  respiration  becoming  feeble, 
cyanosis  increasing,  the  heart  failing,  a  stuporous  condition  developing 
sometimes  with  convulsions  and  death  taking  place  after  24  to  48  hours 
or  sometimes  not  for  several  days  or  a  week.     In  other  instances  the  child 


DIPHTHERIA 


451 


dies  suddenly  from  lack  of  air  in  one  of  the  suffocative  attacks.  In  the 
cases  which  recover,  relief,  at  first  partial  and  then  permanent,  may  follow 
the  coughing  up  of  membrane,  or  the  stenosis  may  gradually  disappear. 

Laryngeal  diphtheria  is  a  frequent  form  of  the  disease.  In  the  1962 
cases  of  the  Boston  City  Hospital,  reported  by  Burrows,^  laryngeal  ste- 
nosis occurred  in  17  per  cent. 

Diphtheria  may  be  classified  also  according  to  the  character  of  the 
symptoms,  the  severity,  and  the  degree  of  constitutional  infection. 

Mild  Diphthekia. — Not  infrequently 
the  disease  is  of  so  mild  a  nature  that  it 
is  either  entirely  overlooked  or  a  positive 
diagnosis  made  possible  only  by  bacterio- 
logical examination.  Constitutional  symp- 
toms are  nearly  or  entirely  absent.  As 
already  stated  primary  nasal  diphtheria 
is  often  of  this  nature,  for  unless  mem- 
brane can  be  discovered — and  it  is  not 
always  present — the  diagnosis  is  entirely 
bacteriological,  since  the  profuse  nasal 
discharge,  although  severe,  could  readily 
depend  upon  some  other  affection. 

In  other  cases  there  are  only  the 
sjTnptoms  of  a  lacunar  tonsillitis,  the  child 
suffering  from  sore  throat  and  some  degree 
of  fever,  but  not  from  any  constitutional 
depression  (Fig.  136).  Should  an  examina- 
tion of  the  throat  chance  to  be  made  some 
of  the  tonsillar  crypts  are  found  filled  with 
secretion  exactly  as  in  ordinary  lacunar 
tonsillitis.  This  deposit  may  disappear  in 
24  hours  or  less  and  leave  the  patient 
feeling  completely  well.  Diphtheria  bacilli 
will,  however,  be  found  in  the  throat  on 
bacteriological  examination.  Sometimes 
these  cases  persist  as  apparent!}^  simple 
lacunar  tonsillitis  for  a  few  days  and  then 
develop  membrane  and  run  the  ordinary 
course  of  diphtheria.  In  other  cases  a 
rapid  recovery  of  the  tonsillitis  is  followed 
in  a  few  days  by  the  developmen  t  of  laryngeal 
diphtheria,  and  in  still  others  the  diphtheritic 
lacunar  tonsiUitis  is  rather  persistent  and  is  accompanied  by  a  degree 
of  constitutional  depression  out  of  all  proportion  to  the  lesions  seen 
in  the  throat,  although  it  may  perhaps  not  be  sufficient  to  confine  the 
patient  to  bed. 

Catakrhal  Diphthkria. — This  term  is  applied  to  the  mild  cases  in 
which  there  is  an  entire  absence  of  membrane  in  either  the  nose  or  throat, 
the  lesions  being  apparently "shnply  those  of  a  catarrhal  inflammation. 
Constitutional  symptoms  are  absent  or  insignificant.  I^ii^iitheria  bacilH 
are,  however,  found  on  bacteriological  study,  and  histological  examination 
shows  the  characteristic  pathological  changes  in  the  epithelium  of  the 
mucous  membrane.  As  in  lacunar  diphtheria  the  disease  may  give  rise 
to  laryngeal  involvement. 

'  Loc.  cit. 


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Diphtheria. 
J.  A.  S.,  aged  4  years.  Deposit 
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slight  submaxillary  swelling. 
General  condition  good.  Slight 
albuminuria.  3000  units  antitoxin 
given  on  Apr.  8,  although 
symptoms  already  improving. 


452  '  THE  DISEASES  OF  CHILDREN  1 

Severe  Faucial  and  Nasopharyngeal  Diphtheria. — As  laryngeal 
diphtheria  is  always  a  most  dangerous  affection,  only  the  cases  of  severe 
faucial  diphtheria  are  considered  in  this  connection.  Many  of  these  are 
well  called  "septic  diphtheria,"  the  general  sjanptoms  being  those  of 
profound  sepsis,  the  streptococci  appearing  to  share  with  the  diphtheria 
bacilli  in  the  poisoning  of  the  patient.  Others  owe  their  severity  entirelj'' 
to  the  action  of  the  diphtheria  toxin.  These  grave  cases  may  begin  as 
ordinary  ones  and  then  steadily  grow  worse,  or  the  onset  may  be  sudden 
and  severe.  The  membrane  is  widespread;  the  tonsils  and  adjacent 
parts  greatly  swollen,  often  assuming  a  gangrenous  appearance;  the 
mucous  membrane  of  the  nose  shares  in  the  process  and  secretes  an 
abundant  offensive  mucopurulent  fluid.  Hemorrhage  may  take  place 
from  the  mouth  and  nose;  the  lips  are  swollen,  fissured  and  sometimes 
exhibit  membrane,  as  does  occasionally  the  lining  of  the  cheeks;  the 
tongue  is  thick  and  dry;  the  eyes  are  sometimes  involved  in  the  process; 
the  cervical  lymphatic  glands  are  greatly  swollen  and  often  the  peri- 
glandular connective  tissue  also.  Respiration  through  the  nose  is  much 
obstructed.  Swallowing  may  be  difficult  and  food  regurgitated  through 
the  nose.  The  face  is  peculiarly  pale  and  more  or  less  cyanotic,  and  the 
surface  of  the  body  pale  or  sometimes  exhibiting  petechia  or  a  dusky 
redness;  the  extremities  are  cold;  the  pulse  feeble  and  rapid,  or  occasion- 
ally unusually  slow.  The  heart  shows  evidence  of  increasing  dilatation 
and  loss  of  muscular  tone,  the  sounds  being  weak  and  mumiurs  some- 
times present.  The  temperature  is  variable,  sometimes  low,  often  high, 
and  subject  to  marked  fluctuations.  Abdominal  pain,  vomiting,  and 
diarrhea  are  common  and  prostration  extreme.  The  mind  may  be  clear 
or  there  may  be  restlessness  or  delirium  or,  oftener,  profound  apathy  or 
stupor.  The  urine  is  frequently  scanty  and  contains  tube-casts  and 
albumin  in  large  amount;  the  spleen  is  enlarged. 

The  attack  lasts  a  variable  time.  The  development  of  the  membrane 
reaches  its  height  in  4  or  5  days,  and  no  change  in  it  may  be  apparent  for 
several  days  more.  At  the  end  of  about  the  1st  week  it  begins  to  disin- 
tegrate in  favorable  cases,  and  may  disappear  in  a  few  days  more.  Some- 
times, however,  it  persists  for  2  weeks  or  longer.  After  its  disappearance 
the  mucous  membrane  is  left  raw-looking  and  sometimes  ulcerated.  The 
toxic  sjonptoms  reach  their  height  with  the  maximum  growth  of  the 
pseudomembrane,  and  although  usually  ameliorating  as  this  disappears, 
by  no  means  always  do  so,  and  in  any  event  improve  only  slowly.  A 
complicating  larygeal  diphtheria  is  not  likely  to  develop  after  the  1st  week. 
The  course  is  not  usually  much  longer  than  a  week  in  fatal  cases,  the 
child  dying  generally  from  increasing  debility  or  bronchopneumonia; 
or  more  unexpectedly  from  uremic  convulsions,  heart-failure,  or  involve- 
ment of  the  larynx.  Sometimes  the  fatal  ending  occurs  only  after  im- 
provement in  local  symptoms  has  commenced  and  convalescence  seems 
assured;  and  may  even  be  delayed  until  the  3d  week  of  the  disease  or  later. 
Malignant  diphtheria  is  a  term  applied  to  the  very  worst  of  the 
severe  cases.  The  sjonptoms  described  are  seen  in  a  specially  marked 
form.  The  pseudomembrane  is  widespread  and  the  process  sometimes 
necrotic  or  gangrenous;  the  toxemic  symptoms  are  usually  severe;  the 
involvement  of  the  cervical  glands  and  cellular  tissue  great;  and  purpuric 
patches  and  hemorrhages  from  various  mucous  membranes  may  be 
present.     Death  occurs  in  24  to  48  hours  from  the  onset. 

Unusual    Localizations. — Membrane    may    appear    in    unusual 
regions,  either  primarily,  or  secondarily  to  diphtheria  of  the  throat  or 


DIPHTHERIA 


453 


I 


^AJ 


y 


nose.  In  very  severe  cases  it  may  spread  to  the  buccal  cavity,  lips,  or 
the  adjacent  portion  of  the  face.  In  one  instance  I  observed  it  on  the 
lining  of  the  cheeks  before  it  could  be  discovered  in  the  throat,  the  pri- 
mary lesion  in  this  instance  appearing  to  be  on  a  circumcision  wound. 
Diphtheria  of  the  conjunctiva  is  rare.  The  disease  may  be  primary  or 
secondary  upon  the  penis  or  the  scrotum,  producing  great  swelling,  or 
upon  the  vagina  and  vulva.  In  the  last  the  genitals  are  much  infiltrated 
and  a  thin,  irritating  discharge  excoriates  the  neighboring  skin.  Any 
cutaneous  wound,  especially  that  of  tracheotomy,  or  even  an  eczematous 
area  may  be  attacked  by  the  diphtheritic  process,  especially  in  much 
debilitated  subjects.  Exceptionally  it  may 
be  primary  in  the  bronchi  and  spread 
thence  to  the  larynx.  Secondary  in- 
volvement of  the  trachea  and  bronchi  is 
common  (Fig.  137);  that  of  the  tongue, 
esophagus,  stomach  and  intestines  rare. 

Complications  and  Sequels.^ — One  of 
the  most  frequent  complications  of  diph- 
theria is  bronchopneumonia.  This  is  par- 
ticularly liable  to  occur  when  the  larynx  is 
involved;  in  severe  septic  cases;  and  in 
infancy.  It  depends  not  only  upon  the 
presence  of  the  diphtheria  bacillus,  but 
upon  associated  microorganisms,  especially 
the  streptococcus  and  the  pneumococcus. 
It  may  develop  at  any  time  during  the 
course  of  the  disease  and  may  be  found 
at  autopsy  in  over  }^  of  the  cases.  Croup- 
ous pneumonia  is  only  an  accidental 
complication. 

Cardiac  failure  is  one  of  the  most 
dreaded  of  complications  or  sequels.  It 
results  from  degeneration  of  the  cardiac 
muscles  or  ganglia,  or  an  involvement  of 
the  pneumogastric  nerve.  Alteration  of 
the  bundle  of  His  may  or  not  be  present. 
In  other  instances  it  is  produced  by  the 
formation  of  a  heart-clot.  It  may  occur 
at  any  time  during  the  course  of  the 
disease;  even  upon  the  1st  day  in  malignant  cases;  but  is  witnessed 
most  frequently  as  a  sequel  in  the  3d  or  4th  week  during  convalescence, 
and  generally  after  severe  attacks  of  diphtheria.  If  developing 
during  the  attack  it  takes  place  oftenest  while  the  disease  is  at  its 
height,  or  after  the  membran^  has  nearly  or  quite  disappeared.  The 
evidences  of  heart-failure  may  come  on  graduall}^,  lasting  3  or  4  days  or 
less,  and  consist  in  abdominal  pain;  obstinate  vomiting;  dyspnea;  weak, 
compressible  pulse  which  is  usually  rapid  and  irregular,  sometimes  slow; 
feeble  heart-tones  somcthnes  with  faint  "accidental"  murmurs  or  a 
galop  rhythm,  and  the  percussion  evidences  of  carthac  dilatation.  The 
surface  of  the  body  is  pale  and  the  tissues  may  be  dropsical.  In  other 
cases  heart-failure  is  abrupt,  the  child  dj'ing  suddenly  when  raised  or 
when  moving  itself  in  bed,  or,  during  convalescence,  when  walking  about 
the  room  or  even  after  undue  excitement. 

Sometimes  repeated  attacks  of  impending  heart-failure  occur  extend- 


/ 


'Y 


Fig.  137. — Unusually  Well- 
developed  Trachial  and 
Bronchial  Casts. 

From  a  case  of  diphtherial 
croup.  (Lennox  Browne,  The  Throat 
and  Nose  and  Their  Diseases, 
1899,  5lh  Ed.,  529.) 


454  THE  DISEASES  OF  CHILDREN 

ing  in  all  over  a  considerable  period,  to  be  followed  finally  by  recovery  or 
by  a  fatal  ending.  Accompanying  this  condition  there  is  generally 
emaciation  and  loss  of  appetite  and  strength.  Moderate  disturbance  of 
the  heart,  as  shown  by  irregular  and  rapid  pulse,  faintness,  and  shortness 
of  breath,  is  very  common  in  diphtheria.  White  and  Smith^  found 
cardiac  symptoms  in  878  out  of  946  cases  of  diphtheria.  Occasionally 
permanent  valvular  lesions  persist  as  sequels. 

Nephritis  is  a  frequent  complication  of  diphtheria,  evidenced  by  the 
occurrence  of  moderate  albuminuria  in  from  }4  to  %  of  all  cases,  and  in 
nearly  every  case  at  all  severe.  Baginsky-  found  albuminuria  417  times 
in  993  cases  of  diphtheria,  and  in  256  of  these  there  were  morphological 
elements  present  also.  It  depends  upon  degeneration  of  the  renal  epithe- 
lium through  the  action  of  the  toxin.  The  urine  may  be  somewhat 
diminished  in  amount  and  epithelial  cells,  leucocytes,  and  tube-casts, 
generally  hyaline,  are  present,  but  seldom  any  blood.  Dropsy  is  absent. 
Recovery  is  generally  rapid.  Nephritis  is  seen  usually  in  the  1st  or  2d 
week,  and  is,  as  a  rule,  much  less  dangerous  and  persistent  than  that 
connected  with  scarlet  fever.  In  some  severe  instances  a  sudden,  acute 
nephritis  may  develop,  characterized  by  great  diminution  in  the  amount 
of  urine,  a  high  degree  of  albuminuria,  and  epithelial  casts,  yet  only  ex- 
ceptionally by  dropsy  and  symptoms  of  uremia.  Chronic  nephritis  is 
an  unusual  sequel. 

Diphtheritic  Paralysis. — Observed  as  a  complication  during  the  attack 
diphtheritic  neuritis  manifests  itself  in  the  production  of  heart-failure, 
and  occasionally,  in  severe  cases,  of  an  early  palatal  paralysis.  Occur- 
ring in  some  form,  as  a  complication  or  a  sequel,  it  was  seen  in  20.7  per 
cent,  of  2300  cases  of  diphtheria  observed  by  Rolleston.''  As  a  sequel 
it  is  a  cause  of  cardiac  failure,  but  is  especially  seen  in  the  "postdiphthe- 
ritic paralysis"  affecting  various  regions  of  the  body.  It  is  observed 
oftenest  after  severe  attacks  in  those  past  the  period  of  infancy,  but  to 
this  there  are  numerous  exceptions,  and  not  infrequently  it  occurs  when 
the  diphtheritic  affection  of  the  throat  has  been  completely  overlooked. 
The  most  frequent  and  usually  the  first  seat  is  the  soft  palate,  which  ex- 
hibits paralysis  most  frequently  3  or  4  weeks  or  more  after  the  onset  of 
the  attack  of  diphtheria.  Baginsky*  found  this  symptom  68  times  in  993 
cases  of  diphtheria.  The  speech  becomes  nasal  and  fluids  pass  into  the 
nose  when  attempts  at  swallowing  are  made.  The  palate  is  relaxed  and 
does  not  move  with  phonation  and  the  palatal  reflex  is  abolished.  With 
this  paralysis  is  generally  associated  a  loss  of  the  patellar  reflex,  even  in 
cases  where  no  sign  of  neuritis  is  discoverable  beyond  the  palate.  In- 
deed the  patellar  reflex  may  be  abolished  without  any  palatal  involve- 
ment. Early  in  the  attack  the  paralysis  may  extend  in  some  cases  from 
the  palate  to  the  pharyngeal  and  laryngeal  muscles,  with  the  result  that 
liquids  readily  enter  the  trachea  when  swallowing  is  attempted,  and  that 
respiration  may  be  interfered  with  by  the  laryngeal  involvement. 

Next  in  frequency  and.  in  order  of  development,  although  much  less 
common,  is  paralysis  of  the  ocular  muscles,  producing  strabismus,  loss 
of  accommodation,  dilatation  of  the  pupils  and  ptosis  or  sometimes  other 
evidences  of  neuritis  of  the  third  nerve.  The  nerves  of  the  face  may 
exceptionally  be  attacked,  and  not  uncommonly  those  of  other  parts  of 

1  Boston  Med.  and  Surg.  Journ.,  1904,  CLI,  433. 

2  Nothnagel,  Spec.  Path.  u.  Therap.,  II,  226. 

3  Arch,  of  Pediat.,  1913,  XXX,  335. 
*  Loc.  cit.,  209. 


DIPHTHERIA  455 

the  body,  especially  the  lower  extremities.  In  the  latter  event  there 
develop  paresthesia,  pain,  and  difficulty  in  walking  owing  to  lack  of 
power  or  of  coordination.  The  condition  is  that  seen  in  multiple  neuritis 
of  any  sort  and  the  electrical  reactions  are  the  same.  Less  often  the  arms 
share  in  the  ataxia  and  loss  of  power,  and  occasionally  the  head  drops 
forward  from  involvement  of  the  muscles  supporting  it.  In  bad  cases  the 
child  may  be  almost  powerless  and  respiration  may  become  difficult 
through  paralysis  of  the  abdominal  and  thoracic  muscles  and  of  the 
diaphragm.  Death  may  result  from  inability  to  swallow,  interference 
with  respiration,  or  the  cardiac  paralysis  already  referred  to. 

In  the  majority  of  cases,  however,  the  paralysis  affects  only  the  palate 
and  the  patellar  reflexes  and  often  the  ocular  muscles  as  well,  and  re- 
covery begins  in  about  2  weeks  and  advances  rapidly.  When  the  affec- 
tion is  more  widespread,  convalescence  is  much  slower.  Rarely  there 
occurs  a  cerebral  paralysis  of  the  hemiplegic  type.  Dynkin^  was  able  to 
collect  72  reported  cases,  and  Ilolleston^  80  cases. 

Digestive  disturbances  are  frequently  seen  in  severe  cases.  The  vomit- 
ing which  attends  heart-failure  has  already  been  referred  to.  Diarrhea 
may  occur,  dependent  upon  inflammation  other  than  of  a  pseudomem- 
braneous  nature. 

Prolonged  anemia  and  debility  are  frequent  sequels  after  severe  cases 
and  to  some  extent  after  all.  Chronic  rhinitis  is  a  common  sequel  and 
otitis  media  is  often  seen,  although  less  frequently  than  after  other  infec- 
tious diseases.  It  arises  generally  by  infection  through  the  Eustachian 
tube.  Rolleston^  reported  it  in  4.10  per  cent,  of  5076  cases  in  the  Metro- 
politan Asylums  Board's  Hospitals. 

Various  cutaneous  eruptions  may  occur,  among  these  being  a  diffuse 
multiform  erythema.  Herpes  is  sometimes  seen  (4  per  cent.  Rolleston).'* 
Purpuric  eruptions  may  be  observed  in  malignant  cases.  Various  urti- 
carial and  erythematous  eruptions  develop  after  the  use  of  antitoxin. 
(See  Treatment.) 

Other  infectious  diseases  may  be  associated  with  diphtheria,  promi- 
nent among  these  being  scarlet  fever  and  measles.  Chicken-pox,  small- 
pox, whooping  cough  and  typhoid  fever  may  occur  in  combination  with 
diphtheria. 

Among  more  unusual  complications  may  be  mentioned  pleurisy,  endo- 
carditis, pericarditis,  cutaneous  emphysema — the  result  of  necrosis  in 
the  pharynx — arthritis,  meningitis,  and  thrombosis  or  embolism  in  the 
brain  or  extremities,  the  latter  perhaps  followed  by  gangrene.  Ran- 
some  and  Corner^  could  collect  but  9  cases  of  this  from  medical  literature, 
including  1  of  their  own;  and  Rolleston*^  but  11.  I  have  seen  it  in 
1  unreported  instance,  and  another  has  been  reported  by  Gunson.^ 

Relapse. — This  is  not  as  rare  as  often  supposed,  Rolleston^  finding 
it  in  about  1.5  per  cent,  of  2560  cases.  It  consists  in  the  reappearance  of 
the  symptoms  of  the  disease  within  a  few  weeks  after  the  onset  of  the 
first  attack  and  before  the  germs  have  left  the  system.  The  occurrence 
of  measles  during  convalescence  from  diphtheria  is  liable  to  be  followed 
by  a  re-development  of  the  diphtheritic  process. 

1  Jahrb.  f.  Kindorh.,  19i;i,  LXXVIII,  Erganzungsh.,  207. 

2  Clin.  Journ.,  1913,  XLII,  12. 

3  Brit.  Jour.  Child.  Dis.,  1915,  XII,  18. 

*  Brit.  Joura.  Doriuiitol.,  1907,  XIX,  375. 
'"Lancet,  1911,  I,  94. 
6  Brit.  .Jour.  Child.  Dis.,  1910,  VII,  529. 
'  Brit.  Jour.  Child.  Dis.,  191t>,  XIII,  237. 
8  Brit.  Jour.  Child.  Dis.,  1907,  IV,  332. 


456  THE  DISEASES  OF  CHILDREN  1 

Recurrence.- — Recurrence  is  frequently  seen,  protection  given  by- 
one  attack  appearing  to  continue  but  a  very  short  time,  probably  only 
a  few  weeks  or  months,  after  which  there  is  no  certain  immunity,  and 
some  individuals  even  seem  predisposed  to  repeated  attacks.  Yet  recur- 
rences as  compared  with  the  total  number  of  cases  of  diphtheria  are  not 
very  common  and  are  prone  to  be  less  severe  than  the  first  attack.  It  is 
uncertain  to  what  extent  this  depends  on  the  acquired  immunity  which 
increases  as  the  individual  grows  older.     (See  p.  460.) 

Prognosis. — The  mortality  of  diphtheria,  always  high,  has  varied 
much  in  different  periods,  even  before  the  introduction  of  antitoxin 
treatment.  Epidemics  have  differed  greatly  in  their  severity,  depend- 
ing probably  on  varying  degrees  of  virulence  of  the  germ.  Since  the 
last  portion  of  the  19th  century  the  disease  as  a  whole  has  certainly 
become  less  serious,  although  this  diminishing  severity  has  been  affected 
in  part  by  the  employment  of  antitoxin,  and  in  part  by  the  application  of 
bacteriological  diagnosis,  by  which  very  many  mild  cases  are  recognized 
which  would  otherwise  have  passed  undetected. 

Yet  the  prognosis  in  individual  cases  is  always  most  uncertain. 
Unfavorable  symptoms  may  readily  develop  in  cases  which  at  first  ap- 
peared to  be  mild,  and  unexpected  complications  and  sequels  may  add 
very  greatly  to  the  danger.  The  favorable  influence  of  the  employment 
of  antitoxin  is  certainly  very  great.  This  has  been  so  uniform  an  experi- 
ence that  it  no  longer  demands  proof.  A  few  statistics  may,  however,  be 
given  by  way  of  illustration.  Burrows  ^  found  that  for  15  years  prior  to  the 
introduction  of  antitoxin  the  mortality  in  Boston  had  been  30.8  per  cent., 
whereas  in  1962  cases  treated  in  the  Boston  City  Hospital  in  a  single  year 
after  this  period,  the  mortality  had  fallen  to  12.23  per  cent.,  or,  if  those 
moribund  on  admission  were  deducted,  9  per  cent.  The  statistics  of  the 
New  York  Board  of  Health  (Northrup)-  showed  a  mortality  of  34.9  per 
cent,  in  27,210  cases  treated  without  antitoxin,  and  only  15  per  cent,  in 
56,425  cases  treated  with  it.  The  report  of  the  Metropolitan  Asylum 
Board's  Hospitals  for  London  (Herringham)^  gave  a  mortality  of  30.25 
per  cent,  in  11,704  cases  before  the  introduction  of  antitoxin,  and  from 
22.5  to  9.29  per  cent,  in  the  years  following  this.  Most  of  the  published 
statistics  are,  to  a  large  extent,  from  hospital  practice,  and  are  virtually 
alike  in  the  diminished  mortality  shown.  In  purely  private  practice  the 
results  with  antitoxin  are  still  better.  In  1610  such  cases  in  St.  Louis, 
collected  by  Zahorsky*  the  mortality  was  but  1.5  per  cent. 

The  favorable  effects  of  antitoxin  treatment  have  been  especially 
marked  in  laryngeal  cases.  According  to  the  investigations  of  the 
American  Pediatric  Society,^  before  the  employment  of  antitoxin  about 
73  per  cent,  of  cases  of  laryngeal  diphtheria  died,  while  in  1704  cases 
treated  with  antitoxin  in  private  practice  the  mortality  was  but  21.12 
per  cent.  In  15,148  laryngeal  cases  occurring  in  the  practice  of  New  York 
City  physicians,  as  quoted  by  Biggs  and  Guerard,^  all  treated  with  anti- 
toxin, the  mortality  was  but  16.6  per  cent.  Moreover  the  employment 
of  antitoxin  certainly  appears  to  have  diminished  greatly  the  necessity 
of  operative  treatment.  The  report  of  the  American  Pediatric  Society 
showed  that  about  60  per  cent,  of  the  laryngeal  cases  thus  treated  did  not 

1  Loc.  cif.,  125. 

2  Nothnagel's  Encyclopedia,  American  Ed.,  Diphtheria,  143. 

3  Albutt  and  Ilolleston's  Syst.  of  Med.,  I,  1630. 
1  Med.  News,  1903,  LXXXII,  1085. 

5  Med.  News,  1897,  LXX,  632. 

6  Med.  News,  1896,  LXIX,  677. 


DIPHTHERIA  457 

need  intubation,  while  previously  about  90  per  cent,  required  it.  The 
mortality  also  of  cases  requiring  intubation  has  diminished  under  the 
influence  of  antitoxin.  In  639  such  cases  without  antitoxin  reported 
by  McCollomHhere  was  a  mortality  of  82.49  per  cent.,  while  1478  intu- 
bated cases  receiving  antitoxin  hacl  a  mortality  of  only  41.4  per  cent. 
Siegert's^  37,000  collected  cases  of  tracheotomy  and  intubation  showed  a 
mortality  of  60.55  per  cent,  before  the  employment  of  antitoxin  and  only 
35.70  per  cent,  after  this  period. 

The  prompt7iess  with  which  the  serum  treatment  is  commenced  is 
important.  In  the  first  report  of  the  American  Pediatric  Society^  the 
mortality  in  cases  injected  on  the  1st  day  of  the  disease  equalled  4.9 
per  cent.  This  increased  steadily  to  22.9  per  cent,  in  cases  first  treated 
on  the  4th  day  and  to  38.9  per  cent,  after  the  4th  day.  Biggs  and 
Guerard^  published  the  following  table  illustrative  of  this  fact. 

T.\BLE  67. — Comparison  of  Date  of  Treatment  and  AIortality 


Date  of  treatment  Cases 


Mortality,  per  cent. 


1st  day  of  the  disease '             1415 

2d  day  of  the  disease 2640 

3d  day  of  the  disease 2340 

4th  day  of  the  disease 1458 

5th  dav  or  later 1912 


3.5 

8.0 

12.8 

23.6 

35.0 


Various  factors  other  than  treatment  influence  the  mortality.  Age 
is  prominent  among  these.  The  disease  is  much  most  fatal  in  infancy, 
largely  on  account  of  the  danger  of  laryngeal  involvement  and  the  develop- 
ment of  bronchopneumonia,  and  becomes  progressively  less  dangerous  as 
age  advances.  The  great  majority  of  deaths  are  in  subjects  less  than  5 
years  old.  In  Burrows^  1962  cases,  all  treated  with  antitoxin,  the  mor- 
tality was  divided  as  follows:  1st  year  40.40  per  cent.;  2d  year  33.9 
per  cent.;  3d  year  23  per  cent.;  4th  year  15.60  per  cent.;  5th  year  14.60 
per  cent.  The  total  mortality  from  birth  to  5  years  was  21.30  per  cent., 
from  5  to  10  years  8.40  per  cent.,  and  from  10  to  15  years  3.10  per  cent. 
In  17,889  fatal  cases  in  the  statistics  of  the  New  York  Board  of  Health^ 
14,554  (81.36  per  cent.)  were  under  5  years  of  age.  Favorable  social 
and  hygienic  conditions  improve  the  prognosis  decidedly.  The  situation 
of  the  membrane  and  the  rapidity  of  its  extension  influences  the  prognosis 
in  individual  cases.  An  abundant  and  rapidly  spreading  or  deeply 
penetrating  membrane  in  the  throat  makes  the  prognosis  grave.  In- 
volvement of  the  larynx,  as  already  stated,  increases  the  mortality 
greatly.  Primary  nasal  diphtheria  is  generally  of  little  danger  to  the 
patient,  although  sometimes  serious  by  its  extension  to  the  larynx.  In 
diphtheria  of  the  nasopharynx,  on  the  other  hand,  the  prognosis  is 
unfavorable.  The  development  of  marked  septic  symptoms  is  an  unfavor- 
al)le  prognostic  indication  as  is  also  evidence  of  cardiac  weakness.  The 
Boston  City  Hospital  Cases  showed  that  the  mortality  was  often  directly 
in  proportion  to  the  rapidity  of  the  pulse.     The  development  of  licinor- 

'  Royer,  Procccdinfrs  Pliila.' County  Med.  Soc,  1905,  XX^■I,  80. 
2  Jiihrbui-h  f.  Kindcrlicilk.,  1900,  Lll,  .56. 
^  Transac.  Am.  I'cd.  Soc,  lS96,iVlll,  21. 

*  Loc.  cit.,  728 

*  Loc.    cit. 

'  Xorthrup,  Loc.  cit.,  j).  24. 


458  THE  DISEASES  OF  CHILDREN 

rhagic  conditions  makes  the  prognosis  extremely  serious.  The  absence 
of  an  increase  of  the  polymorphonuclear  cells  in  the  blood  has  been 
considered  of  bad  import,  although  this  is  not  universally  admitted. 

Among  serious  complications  are  bronchopneumonia  and  an  unusual 
degree  of  albuminuria,  of  anemia,  or  of  lymphatic  enlargement.  Post- 
diphtheritic paralysis  generally  results  favorably  if  the  heart  escapes. 
The  combination  of  measles  with  diphtheria  or  the  development  of  one 
after  the  other  greatly  increases  the  gravity  of  the  case.  Scarlet  fever 
occurring  as  a  complication  is  unfavorable  and  the  case  may  be  readily 
fatal.  If  the  order  is  reversed,  diphtheria  being  the  complication,  the 
prognosis  is  not  so  often  affected.  The  association  of  diphtheria  and 
typhoid  fever  is  dangerous. 

Diagnosis.  Clinical. — Even  without  bacteriological  examination 
the  diagnosis  of  diphtheria  is  usually  easy  in  typical  and  well-developed 
cases.  Early  in  the  disease  or  in  atypical  attacks  it  maj^  be  a  matter  of 
great  difficulty.  It  rests,  in  general,  in  the  case  of  tonsillar  diphtheria 
upon  the  rapid  development  of  pseudomembrane  which  is  removed  only 
with  difficulty  and  which  leaves  a  bleeding  surface  beneath;  the  reform- 
ing of  the  membrane  after  removal;  its  tendency  to  spread  beyond  the 
tonsils;  constitutional  depression  out  of  proportion  to  the  local  symptoms; 
the  frequent  presence  of  albuminuria,  and  of  glandular  enlargement  in  the 
neck,  and  the  common  occurrence  of  paralysis  as  a  sequel.  The  mode 
of  onset  and  the  temperature  curve  are  too  variable  to  be  of  much  diag- 
nostic assistance. 

Mild  attacks  of  diphtheria  are  most  liable  to  be  confounded  with 
follicular  tonsillitis  especially  when  the  separate  foci  of  secretion  in  the 
latter  disease  fuse  and  cover  the  tonsil.  The  onset  of  this  condition  is 
generally  more  sudden,  the  fever  higher;  the  throat  feels  sorer  and  is  of 
a  deeper  red;  the  early  swelling  greater;  the  secretion  is  easily  removed, 
and  there  is  no  spreading  beyond  the  tonsils.  The  patient  often  has 
the  history,  too,  of  having  been  susceptible  to  repeated  similar  attacks. 
It  is  impossible,  however,  to  make  a  positive  diagnosis  between  the 
ordinary  follicular  tonsillitis  and  diphtheritic  folliculitis  without  a 
bacteriological  examination.  Severe  and  even  fatal  streptococcic  inflam- 
mation of  the  tonsils  ma}^  occur,  and  can  be  distinguished  from  diphtheria 
only  by  bacteriological  examination.  Such  cases  are  seen,  for  instance, 
in  scarlet  fever.  Similarly  a  severe  pseudomembranous  inflammation  is 
sometimes  dependent  upon  pneumococcic  involvement. 

Primary  nasal  or  nasopharyngeal  diphtheria  is  often  unrecognized 
because  unsuspected.  It  is  especially  in  infants  and  young  children, 
when  free  nasal  discharge  is  combined  with  excoriation  of  the  lip  and 
nostrils  and  perhaps  the  presence  of  fever,  that  the  secretion  should  be 
studied  bacteriologically  and  an  examination  for  membrane  made. 

Laryngeal  diphtheria  must  be  distinguished  from  stenosis  depending 
upon  other  laryngeal  conditions.  The  persistence  of  stenosis  by  day  as 
well  as  by  night  usuall}^  indicates  the  existence  of  something  more  than 
false  croup,  yet  not  necessarily  so.  The  further  differential  diagnosis 
is  considered  under  Respiratory  Diseases.  The  severe  laryngeal 
stenosis  which  sometimes  accompanies  measles  may  or  may  not  be  diph- 
theritic in  nature.  Only  a  laryngoscopic  examination,  when  this  can  be 
made,  or  a  bacteriological  study  can  finally  determine  the  question. 

The  diagnosis  is  sometimes  difficult  between  diphtheria  and  scarlet 
fever,  but  only  in  anomalous  cases.  The  former  disease  may  exhibit  a 
scarlatiniform  erythema,  while  in  the  latter  the  eruption  may  be  absent, 


DIPHTHERIA  459 

undiscovered,  uncharacteristic,  or  late  in  appearing.  The  onset  of 
scarlet  fever,  however,  is  usually  more  abrupt  and  the  inflammation  of  the 
throat  at  the  outset  more  severe.  Only  a  bacteriological  study  can  settle 
the  diagnosis  in  some  instances.  The  combination  of  the  two  diseases 
may  be  especially  difficult  to  recognize.  Here  the  sequence  of  symp- 
toms is  the  best  guide.  Thrush,  aphthcB  and  ulcerative  stomatitis 
offer  little  practical  difficulty  in  diagnosis.  The  first  two  are  different 
in  situation  and  appearance,  and  the  last  could  suggest  diphtheria  only 
when  this  is  limited  to  the  oral  cavity;  an  occurrence  of  great  rarity. 
VincenVs  angina  may  resemble  diphtheria  early  in  the  attack,  and  a 
bacteriological  examination  may  be  required  to  distinguish  them.  The 
deposit  in  Vincent's  angina  is  more  liable  to  involve  the  tongue,  cheeks, 
and  gums.  When  on  the  tonsils  it  is  usually  confined  to  one  side,  is 
slower  in  developing,  more  necrotic  than  pseudomembranous,  and  tends 
to  produce  a  deeper  and  more  punched-out  ulcer. 

Bacteriological. — Although,  therefore,  the  clinical  diagnosis  of  diph- 
theria can  be  made  with  positiveness  in  many  cases  of  the  disease,  the 
bacteriological  diagnosis,  as  already  indicated,  is  always  of  value  and 
often  indispensible.  In  all  suspicious  cases  cultures  should  be  taken  as 
early  as  possible.  The  secretion  is  obtained  by  rubbing  the  affected 
area,  or  the  posterior  portion  of  the  pharynx  when  the  larynx  is  involved, 
firmly  with  a  swab  of  sterilized  cotton  or  a  platinum  wire  loop  and  then 
transferring  the  germs  in  the  same  manner  to  the  blood-serum  culture- 
medium  in  a  test-tube.  After  about  6  hours,  or  with  more  certainty  after 
12  hours,  this  may  be  examined  for  the  presence  of  the  diphtheria  bacilli. 
The  culture  should  not  be  taken  immediately  after  an  antiseptic  applica- 
tion has  been  made  to  the  suspected  region.  It  can  also  not  be  depended 
upon  if  made  late  in  the  course  of  the  disease.  Since  the  surface  of  a 
thick  membrane  may  fail  to  give  a  positive  culture,  inasmuch  as  the 
bacilli  here  are  dead,  a  lower  layer  should  be  reached  if  possible.  A 
single  negative  culture  is  not  sufficient  in  suspicious  cases.  A  test  of  the 
virulence  of  the  germs  is  sometimes  necessary,  effected  by  injecting  them 
into  guinea-pigs.  Sometimes  the  diagnosis  of  diphtheria  can  be  made  by 
the  immediate  staining  of  smear-preparations  from  the  throat  or  nose^ 
The  failure  to  find  the  germs  under  these  conditions  is  not,  however,  a 
proof  that  the  disease  is  not  diphtheria. 

Regarding  the  diagnostic  value  of  the  diphtheria  bacillus,  while  this 
is  undoubtedly  very  great,  reliance  should  not  be  placed  on  it  alone.  A 
case  which  is  clinically  diphtheria  should  be  treated  as  such  in  spite  of 
the  failure  to  find  the  specific  germ.  On  the  other  hand  the  mere  pres- 
ence of  diphtheria  bacilli  in  healthy  throats  does  not  constitute  diph- 
theria (see  p.  444)  and  there  is  no  reason  why  the  same  accidental  pres- 
ence should  not  be  found  in  persons  whose  throats  exhibit  a  catarrhal  or 
even  a  lacunar  tonsillitis.  Nevertheless,  the  combination  of  diphtheria 
bacilli  with  catan-hal  pharyngitis  or  rhinitis  generally  indicates  the 
existence  of  dij)hth('i'ia  and  the  jii'ovisional  diagnosis  of  this  disease  should 
l)e  made. 

As  to  the  (liphthcroid  bacilli  other  than  the  virulent  Klebs-Loffler 
germ,  there  is  nuu-h  difference  of  opinion.  There  may  be  found  in  the 
throat  an  organism  which  is  in  reality  the  diphtheria  bacillus  although 
non-virulent  to  guinea-pigs.  There  is  also  described  the  pseudo-diph- 
theria bacillus  of  Hofmann-Wellenhof  already  referred  to  (p.  445). 
Neither  germ  is  capable  of  producing  diphtheria,  and  neither  is  common  in 
cases  which  are  apparently  clinically  this  disease;  but  whether  thej'  are 


460  THE  DISEASES  OF  CHILDREN 

in  reality  but  variants  of  the  diphtheria  bacillus,  capable  under  favorable 
circumstances  of  again  becoming  virulent,  is  not  certainly  determined. 
The  difficulty  in  making  a  diagnosis  of  diphtheria  solely  upon  the  cultural 
findings  is  therefore  great.  Van  Riemsdyk'  found  bacteria  resembling 
diphtheria-bacilli  in  50  per  cent,  of  children  examined  in  a  region  where 
there  had  been  no  diphtheria  for  10  j^ears,  and  Kolmer^  reported  diph- 
theria-bacilli, although  avirulent,  in  40  per  cent,  of  cultures  from  the 
penis  of  100  healthy  boys. 

Treatment.  Prophylaxis.  Natural  Immunity. — Bearing  closely 
upon  the  necessity  of  immunization  is  that  of  natural  immunity.  It 
had  been  recognized  that  infants  in  the  early  months  of  life  were  less 
susceptible  to  diphtheria  than  after  this  period  and  during  early  childhood ; 
and  that  through  later  childhood  there  was  a  slowly  increasing  return  of 
immunity.  The  investigations  of  Schick^  have  established  these  facts 
upon  a  scientific  basis.  He  found  that  the  intracutaneous  injection  of 
3-^0  of  the  minimum  dose  of  toxin  lethal  for  a  guinea-pig,  diluted  with  0.05 
to  0.2  c.c.  of  normal  salt  solution,  will  produce  in  non-immune  persons 
an  erythema,  while  in  those  immune  there  is  no  reaction  whatever. 
In  making  the  test  a  small,  accurately  graduated  syringe  is  employed, 
with  a  very  fine  special  needle;  the  skin  pinched  into  a  fold;  and  the 
needle  inserted  into  the  skin,  not  beneath  it.  If  no  antitoxin  is  present 
in  the  patient's  circulation,  a  red,  slightly  edematous  spot  of  erythema, 
0.5  to  2  cm.  in  diameter,  with  a  brownish  tinge,  appears  within  24  to 
48  hours  (Fig.  138).  It  begins  to  disappear  within  from  7  to  10  days, 
leaving  a  brownish  pigmented  area  with  superficial  desquamation.  The 
value  of  this  test  has  been  confirmed  by  other  investigators,  among  them 
in  the  United  States  being  Moody,*  Park,  Zingher  and  Serota,^  Kolmer 
and  Moshage,^  Shaw  and  Youland^  and  others.  A  comparison  of  the 
statistics  given  by  the  writers  mentioned",  the  figures  being  approximations 
only,  shows  that  a  positive  reaction;  i.e.  an  absence  of  immunity,  was 
present  in  the  new  born  in  7  per  cent.  (Schick) ;  in  the  1st  year  in  35  to 
45  per  cent. ;  from  1  to  2  years  in  55  to  60  per  cent. ;  from  2  to  5  years  in 
about  66  per  cent.;  from  6  to  8  years  in  35  to  45  per  cent.;  and  from 
8  to  15  years  in  25  to  30  per  cent.  Tests  by  Zingher^  give  decidedly  lower 
figures.  Pseudo-reactions  are  described  as  less  sharply  defined,  more 
infiltrated,  and  disappearing  in  48  hours. 

The  practical  value  of  the  Schick  test  is  great,  in  that  it  enables  us 
to  determine  what  subjects  are  already  immune.  Those  who  give  a 
negative  reaction  do  not  need  antitoxin  injections.  This  is  a  matter  of 
moment  from  an  economical  point  of  view  when  considerable  numbers  of 
patients  are  to  be  immunized,  and  is  important,  too,  when  an  anaphy- 
lactic reaction  is  feared  in  those  who  have  previously  received  antitoxin. 
Since  about  40  to  50  per  cent,  of  children  from  1  to  15  years  are  naturally 
immune  (Kolmer  and  Moshage),  it  is  evident  that  artificial  immuniza- 
tion is  required  in  only  half  of  the  children  who  have  been  exposed.  In 
the  first  6  months  of  life  there  appears  to  be  in  most  cases  a  natural 
immunity. 

1  Niederl.  Tijdsch.  v.  Geeneesk.,  1914,  1066. 

2  Arch,  of  Fed.,  1912,  XXIX,  94. 

3  Mtinch.  med.  Woch.,  1913,  LX,  2608. 

*  Journ.  Amer.  Med.  Assoc,  1915,  LXIV,  1206. 
5  Arch,  of  Pediat.,  1914,  XXXI,  481. 
«  Amer.  Jour.  Dis.  Child.,  1915,  IX,  189. 

7  Trans.  Amer.  Pediat.  Soc,  1916,  XXVIII,  329. 

8  Amer.  Jour.  Dis.  Child.,  1916,  XI,  269. 


Fio.  138. — The  Schick  Reaction-  i>f  Diphtheria. 

(n)  to  (d)  Typical  positive  reactions  48  hours  after  test:  (a)  strongly  positive  reaction, 
with  vesiculation  of  the  surface  layers  of  the  epithelium,  which  is  seen  occasionally  in  individ- 
uals who  have  practically  no  antitoxin;  {h)  and  (c)  positive  reactions;  (d)  a  moderately  positive 
reaction;  (c)  fading  reaction  1  week  after  test;  shows  rednos.'^,  scalinp  and  Ijeninninp  picmon- 
tation;  (/)  after  2  weeks;  (g)  after  3  weeks;  (h)  faint  piRiiuMitation  after  1  weeks.  (Zmghcr, 
Ar.icrican  Journal  of  Diseases  of  Children,  April,  1916.) 


DIPHTHERIA  461 

Immunization. — Upon  the  development  of  a  case  of  diphtheria,  all 
susceptible  members  of  the  household,  proven  by  the  Schick  test  to  be  so, 
should  receive  an  immunizing  injection  of  diphtheria  antitoxin.  When 
for  any  reason  the  test  cannot  be  carried  out,  certainly  all  the  children 
of  the  family  should  be  immunized,  and  it  is  no  doubt  safer  to  treat  the 
older  members  in  the  same  way.  The  dosage  employed  should  be  from 
500  to  1000  units,  the  latter  amount  being  used  at  all  ages  except  the 
1st  year  of  life.  The  protection  afforded  is  very  complete  yet  but  of  short 
duration;  not  over  4  weeks  and  often  not  much  longer  than  10  days. 
Consequently  children  in  hospital-wards  should  have  the  immuniza- 
tion repeated  every  3  to  4  weeks,  if  a  repetition  of  the  Schick  test  gives 
a  positive  result. 

In  the  effort  to  produce  a  more  lasting  immunity  v.  Behring^  has  urged 
repeated  subcutaneous  injections  of  a  mixture  of  toxin  and  antitoxin, 
as  first  suggested  for  use  in  children  by  Theobald  Smith  in  1909. ^  The 
protective  action  is  not  effected  until  from  23  to  25  days  (Schreiber),^  and 
often  much  later,  but  continues  at  least  for  months  and  perhaps  for  years. 
It  is  sometimes  of  advantage  to  combine  with  the  toxin-antitoxin  m.ixture 
a  vaccine  of  dead  diphtheria  bacilli.  Park  and  Zingher^  found  that  y. 
Behring's  method  of  immunization  greatly  increased  the  amount  of  anti- 
toxin in  the  blood  of  persons  already  immune;  while  in  the  case  of  those 
non-immune  the  treatment  combined  with  the  vaccine  produces  sooner 
or  later  an  immunity  in  40  out  of  50  individuals  treated.  Inasmuch  as 
the  natural  antitoxin  is  liable  to  be  absent  from  the  blood  especially  in 
infancy,  Zingher^  advises  that  all  infants  below  18  months  of  age  should 
be  actively  immunized,  whether  or  not  they  exhibit  a  Schick  reaction. 

Quarantine. — Persons  suffering  from  diphtheria  should  be  isolated 
until  at  least  2  successive  negative  cultures  show  that  the  bacilli  have 
disappeared  from  the  mucous  membranes.  Persons  merely  suspected  of 
having  the  disease  ought  to  be  quarantined  until  a  bacteriological  study 
can  be  made  and  the  diagnosis  determined  positively.  Other  children  in 
the  family  should  be  kept  from  school,  and,  if  possible,  removed  from  the 
house;  and  should  not  be  allowed  to  mingle  with  others  until  bacterio- 
logical examination  shows  that  no  diphtheria  bacilli  are  present  on  the 
mucous  membranes.  The  nurse  or  members  of  the  famil}'  in  constant 
attendance  upon  the  patient  should  employ  disinfectant  gargles  and 
sprays,  and  should  refrain  from  association  with  others.  When  cultures 
for  any  reason  cannot  be  made — and  this  is  now  exceptional — the  quar- 
antine of  the  patient  should  continue  for  at  least  3  weeks  after  the  mucous 
membranes  are  free  from  a  deposit.  This  ensures  the  disappearance 
of  the  bacilli  in  the  very  large  majority  of  instances,  since  bacteriological 
examination  shows  that  in  probably  80  per  cent,  of  cases  there  are  none 
of  these  germs  to  l)e  founcl  in  1  week,  and  in  90  per  cent,  in  2  weeks, 
after  the  pseudomombrane  has  left  the  throat.  In  882  cases  recorded 
in  the  Department  of  Health  of  Philadelphia  the  average  duration  of 
quarantine  from  the  onset  of  the  disease  to  the  2d  consecutive  nega- 
tive culture  was  15.9  days  (C.  Y.  White). ^  Other  details  in  connection 
with  quarantine  and  disinfection  are  those  appropriate  to  infectious 
diseases  in  general. 

1  Deut.  ined.  Woch.,  1913,  XXXIX.  873. 

2  Journ.  Exper.  Med.,  1909,  XI,  241. 

'  Dcut.  med.  Woch.,  1913,  XXXIX,  9128. 

■•  Bureau  of  Laboratories,  Citv  of  New  York,  1914-1."»,  VIII,  104. 

s  .\iner.  Jour.  Dis.  Child.,  1918,  XVI,  S3. 

®  Personal  cominuuioatioti. 


462  THE  DISEASES  OF  CHILDREN 

Management  of  Carriers. — The  procedure  for  children  of  the  family 
and  for  those  in  constant  close  contact  with  the  patient  has  been  referred 
to  in  the  preceding  paragraph.  What  is  to  be  done  with  carriers  of  other 
sorts;  i.e.  those  who  without  such  known  exposure  are  found  to  have 
diphtheria  bacilli  on  the  mucous  membranes,  is  one  of  the  most  perplexing 
of  problems.  Theoretically  it  would  be  advisable  to  quarantine  all  such; 
but  the  studies  of  Pennington  and  others,  already  referred  to  (p.  445), 
showed  the  manifest  impossibility  of  this  procedure.  Certainly  when 
cases  repeatedly  develop  in  schools  or  hospitals,  the  only  proper  course 
is  to  make  cultures  from  every  individual,  and  to  institute  the  proper 
treatment.     (See  Treatment  of  Carriers,  p.  471.) 

Treatment  of  the  Attack.  General  and  Hygienic. — The  selection 
and  the  care  of  the  sick-room  are  those  described  under  the  Management 
of  Infectious  Diseases  (p.  306).  Fresh  air  and  sunlight  are  of  great 
importance.  The  patient  should  be  confined  absolutely  to  bed  in  a  re- 
cumbent position  no  matter  how  mild  the' attack.  The  diet  should  be 
liquid,  preferably  milk.  The  difficulty  in  swallowing  and  the  distaste 
for  food  which  sometimes  develop  later  in  the  attack,  often  occasion  such 
active  resistance  on  the  part  of  the  child  that  the  curtailing  of  the  fre- 
quency of  feeding  may  be  necessary.  This  applies  also  to  all  local  treat- 
ment in  this  disease,  since  exhaustion  is  such  a  prominent  symptom. 
The  question  of  the  course  to  be  pursued  must  be  determined  for  each 
case  individually.  Feeding  through  a  stomach  tube  or  nasal  tube  is 
frequently  a  great  aid  in  such  cases. 

The  unusual  prostration  characteristic  of  diphtheria  renders  stimula- 
tion, especially  alcoholic,  necessary  in  all  but  the  mildest  cases.  It  is 
usually  better  to  begin  this  early  rather  than  to  wait  for  visible  evidences 
of  exhaustion  to  manifest  themselves.  Comparatively  large  doses  may 
be  required,  a  child  of  2  years  seriously  ill  sometimes  readily  bearing  from  1 
to  2  fl.  drams  (4  to  8)  of  whiskey  or  its  equivalent  every  2  or  3  hours,  the 
quantity  depending  upon  the  character  of  the  pulse  and  of  the  heart- 
sounds  and  the  general  evidences  of  debility.  In  addition,  digitalis, 
camphor,  strychnine,  adrenalin  and  nitrogh^cerine  are  frequently  re- 
quired to  combat  circulatory  disturbances.  These  are  often  best  given 
h3'-podermically.  The  internal  administration  of  bichloride  of  mercury 
in  doses  of  Hq  to  1:30  grain  (0.001  to  0.002)  every  2  hours  was  long 
in  vogue  in  both  pharyngeal  and  laryngeal  diphtheria,  and  appears  to 
have  decided  value.  Tincture  of  the  chloride  of  iron  in  full  doses  was 
for  years  a  favorite  remedy,  but  cannot  be  considered  in  any  way  a 
specific. 

Serum  Treatment. — Of  the  numerous  remedies  formerly  in  use  little 
is  now  heard  since  the  introduction  and  wonderful  success  of  the  serum 
treatment.  (See  Prognosis,  p.  456,  for  statistics.)  This  method, 
first  brought  prominently  before  the  mecUcal  profession  by  von  Behring 
and  Wernicke,^  consists  in  the  injection  into  the  circulation  of  the  patient 
of  the  serum  of  an  animal — the  horse  being  relied  upon  for  this  purpose — 
which  has  received  repeated  injections  of  the  diphtheria  toxin  in  increasing 
doses,  and  which,  as  a  result,  has  developed  in  its  blood  a  body,  perhaps  a 
globulin,  powerfully  antagonistic  to  the  toxin,  and  hence  called  the  anti- 
toxin. This  neutralizes  the  toxin  already  in  the  patient's  blood  and 
checks  the  growth  of  the  membrane  by  inhibiting  further  development  of 
the  bacilli.     The  strength  and  dosage  of  the  serum  is  measured  by  "anti- 

1  Zeitschr.  f.  Hyg.,  1892,  XII,  10. 


^ 


Fici.  243. — A  Hard  Puotkin  C'ird,  Bhokex  into  Two  I'outions. 


i. 


1^'^'. 


.^^  ^ 


)'. 


d  fi 


Vie.  244.— The  Soap  Stool. 
Sl.ow.-^  the  white,  .salve-like  chaniefer. 


\ 


£^^.  /x 


Fic.  24'). — The  Curdy  Stool. 
S1k)\vs  tlic  white,  f:tUy  iiiiisscs,  with  nuictis  of  a  palc-hrowiiish  tint. 


TCT^; 


Fi<;.  210. — The  Cakhoiiydhatk  Std^jl. 
Stiiooth,  Soft,  liDiiiiiticncous,  hrowii  mass.      Infant  fi<l  mi  malt-soup 


^' 


9- 


Fir,.  247. — The  RpTNACH-onEEN  Stool. 
With  a  few  lunii)s  of  fat-curds  and  lart;c  aiiioiint  of  muoiis,  a  portion  of  it  blootl-staincd. 


DIPHTHERIA  463 

toxin  units."  such  a  unit  being  the  amount  of  serum  sufficient  to  neutral- 
ize the  effect  of  100  times  the  close  of  diphtheria  toxin  which  would 
kill  in  4  days  a  guinea-pig  weighing  250  grams  (8.82  oz.).  The  antitoxin 
serum  is  preserved  in  hermetically  sealed  glass  vessels.  It  should  be 
used  promptly  after  it  is  opened. 

Method  of  Emyloyment. — The  antitoxin  can  be  given  with  a  special 
syringe  made  for  the  purpose  and  thoroughh'  sterilized  just  before 
using.  ^Makers  now  frequently  supply  the  serum  in  a  glass  tube,  which 
can  itself  be  used  as  a  syringe,  a  glass  piston  and  hypodermic  needles 
alread}^  sterilized  accompanying  this.  A  region  should  be  chosen  which 
is  not  pressed  upon  in  lying,  the  flank  and  the  abdomen  being  favorable 
situations.  The  skin  should  be  thoroughly  scrubbed  with  diluted  alcohol 
and  the  hands  of  the  operator  cleansed  in  like  manner.  The  air  should  be 
expelled  before  the  needle  is  thrust  under  the  skin.  Local  anesthesia  is 
not  necessary.  A  small  piece  of  adhesive  plaster  or  a  pledget  of  cotton 
afterward  painted  with  collodion  may  be  applied  after  the  needle  is 
withdrawn. 

Dosage. — For  immunizing  purposes  the  amount  to  be  given  varies 
from  500  units  in  the  1st  year  of  life  up  to  1000  units  for  older  children. 
In  average  cases  of  the  disease  over  2  years  of  age  seen  early  3000  to 
5000  units  should  be  given.  If  no  improvement  follows,  this  may  be 
repeated  within  6  to  12  hours  and  the  treatment  continued  perhaps  in 
larger  doses  until  improvement  is  seen.  In  all  severer  cases  in  which  the 
deposit  has  extended  beyond  the  tonsils,  and  in  all  instances  where  in- 
volvement of  the  larynx  is  threatened,  the  initial  dose  should  be  7000  to 
10,000  units,  varying  with  the  age,  and  best  given  intravenously.  These 
doses  are  larger  than  formerly  recommended,  but  it  is  better  to  give  more 
than  really  needed  than  to  use  too  little,  since  the  effects  are  practically 
never  harmful. 

Time  of  Administration. — The  earlier  in  the  disease  the  antitoxin  is 
administered  the  more  certain  and  powerful  the  action  and  the  smaller 
the  amount  required  to  be  effective.  This  is  due  to  the  fact  that  the  anti- 
toxin stops  the  destructive  action  of  the  diphtheria  toxin,  but  cannot 
regenerate  the  cells  which  have  already  been  injured  by  it.  The  com- 
parative results  of  treatment  begun  on  different  days  is  very  strikingly 
shown  in  the  statistics  detailed  under  Prognosis  (p.  457).  When  given 
after  the  3d  day  of  the  disease  much  less  good  can  be  expected.  Never- 
theless, as  there  are  exceptions  to  the  rule,  no  case  should  be  considered 
to  have  lasted  too  long  to  seek  benefit  from  serum  treatment,  and  the 
dose  should  be  large;  while  on  the  other  hand  very  severe  cases  may  be 
already  too  far  advanced,  even  upon  the  1st  day,  to  be  capable  of  being 
benefited.  Even  in  the  mildest  and  the  doubtful  cases,  by  far  the  wisest 
course  is  to  administer  antitoxin  inunediately  without  waiting  for  confir- 
mation of  the  diagnosis  by  liacteriological  examination. 

Results  of  Antitoxin  Treatment. — Favorable  results  following  the 
injection  are  seen  within  12  to  24  hours  and  sometimes  earlier.  They 
consist  in  a  softening  and  separating  of  the  psoudomcmbrane  at  its  edges, 
a  diminution  of  the  glandular  swelling  and  of  nasal  discharge,  and  an 
improvement  in  the  general  condition.  In  many  cases  the  membrane 
disintegi'ates  and  disapjiears  with  surprising  i-apitlity  and  the  tliroat  is 
clear  in  from  3  to  4  days.  If  no  effects  are  seen  the  administration  of  the 
serum  is  repeated  as  described.  Complications  of  diphtheria  depending 
on  damage  already  done  by  the  toxin  or  upon  septic  conditions  are  in  no 
way  benefited  by  antitoxin.     Thus  the  serum  treatment  does  not  appear 


464 


THE  DISEASES  OF  CHILDREN 


to  diminish  the  number  of  cases  of  paralysis,  since  the  damage  done  to  the 
cells  of  the  nei'vous  tissue  takes  place  very  early  in  the  attack.  In  favor- 
able laryngeal  cases  there  is  a  rapid  lessening  of  the  stenosis.  The  good 
effects  of  antitoxin  are  particularly  evident  in  the  reduction  of  the  number 
of  tracheotomies  and  intubations  now  necessary,  as  well  as  in  the  mor- 
tality where  operation  has  been  required.     (See  Prognosis,  p.  456.) 


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Fig.  139.  Fig.   140.  Fig.   141. 

Fig.  139. — Rise   of   Temperature   Promptly   After   Prophylactic   Administration 

OF  Diphtheria  Antitoxin. 
Harry  AI.,  aged  1  year,  4  months.     Recovering  from  grippe.     1200  units  of  antitoxin 
given  on  the  morning  of  Dec.  17. 

Fig.  140. — Febrile  Re.\ction  Promptly  Developing  After  Diphtheria  Antitoxin. 
Chester    E.,   2    years    old.     Convalescent    from    bronchopneumonia.     1235    units    of 
antitoxin  given  on  the  afternoon  of  Mar.  1. 

Fig.  141. — Serum  Sickness  Occurring  7  Days  After  the  Administration  of 

Antitoxin. 

Dorothy  McC,  7  years  old.  Immunizing  dose  of  diphtheria  antitoxin  (2500  units) 
given  on  Feb.  23;  throat  been  slightly  red  and  cultures  positive;  Feb.  25,  cultures  being 
still  positive,  antitoxin  repeated;  Mar.  2,  widespread  eruption  of  urticaria  which  is  giving 
pain;  Mar.  3,  still  widespread  typical  antitoxin  rash;  Mar.  4,  rash  about  gone. 

Unfavorable  Effects  of  Antitoxin. — A  group  of  symptoms  to  which 
the  title  "Serum  Disease"  has  been  applied,  not  infrequently  follows  the 
administration  of  antitoxic  serum.  As  this  condition  is  due  to  the 
introduction  of  a  foreign  blood-serum  independently  of  its  content  of 
diphtheria-antitoxin  contained,  it  would  seem  that  the  smaller  the 
amount  of  serum  used  the  better.  Consequently  concentrated  sera  are 
always  to  be  preferred  as  less  liable  to  produce  unpleasant  after-effects 
and  less  painful  at  the  time  of  injection.  It  is  not,  however,  certain 
that  the  quantity  of  serum  used  bears  any  real  relationship  to  the  pro- 


DIPHTHERIA  465 

duction  of  symptoms.  The  symptoms  are  seen  in  from  5  to  30  per  cent, 
of  the  cases,  and  occur  anywhere  from  the  1st  to  the  17th  day,  although 
oftenest  from  the  5th  to  the  9th  (Sturtevant).^  They  consist  in  erythema 
of  a  scarlatiniform  or  rubeloid  type,  urticaria,  edema,  fever  (Figs. 
139,  140,  141),  vomiting,  painful  articular  swelling,  albuminuria,  malaise, 
headache,  and  general  aching.  Some  or  all  of  these  may  be  present, 
urticaria,  often  widespread  and  lasting  ■  2  to  3  days,  being  the  most 
frequent.  (See  p.  435,  Fig.  ]27.)  Instances  of  sudden  death  follow- 
ing the  injection  have  occurred,  but  these  have  appeared,  certainly 
in  some  cases,  to  be  due  to  the  mere  hypodermic  puncture  in  cases 
of  patients  suffering  from  lymphatism.  (See  Sudden  Death,  p.  216.) 
In  other  cases  grave  symptoms  or  death  have  apparently  been  due 
to  an  unusual  susceptibility  to  the  action  of  an  alien  serum,  such  as 
that  of  the  horse.  It  does  not  appear  proven  that  the  result  is  pro- 
duced by  the  antitoxin  itself.  The  symptoms  in  these  cases  consist  of 
alarming  dyspnea  and  cyanosis  developing  promptly  after  the  injection, 
and  either  passing  away  gradually  or  terminating  fatally  in  a  few  minutes. 
It  is  true  that  repeated  injections  of  antitoxin  at  intervals  separated  by 
months  or  longer  may  produce  an  increasing  sensitiveness  to  the  serum, 
but  the  majority  of  cases  of  sudden  death  have  taken  place  after  the 
period  of  childhood,  after  the  first  injection,  and  in  individuals  with  a 
decided  asthmatic  tendency,  especially  produced  by  approach  to  a 
horse.  Whatever  the  cause,  the  numbers  of  instances  of  dangerous 
symptoms  or  fatal  result  are  so  extremely  few,  as  compared  with  the 
frequency  with  which  antitoxin  has  been  employed,  that  they  must  be 
ignored  for  practical  purposes.  As  the  serum  has  no  action,  either  good 
or  bad,  upon  complications,  it  should  be  given  regardless  of  their  presence. 
In  persons  with  a  positive  asthmatic  history  it  may  be  well  to  omit  the 
administering  of  immunizing  doses,  or,  in  those  with  the  disease,  to  defer 
it  if  the  attack  is  mild.  In  those  positively  requiring  the  use  of  serum  it 
should  be  given  in  a  minute  injection  of  a  few  drops  at  a  time  only,  with 
pauses  of  a  few  minutes  between,  in  order  to  observe  the  development  of 
symptoms,  if  any  are  to  appear. 

Local  Treatment. — Local  treatment  is  of  value  in  so  far  as  it  destroys 
or  removes  the  bacilli,  from  the  affected  mucous  membrane,  or  retards 
their;  growth  or  checks  their  dissemination  by  producing  conditions  of 
cleanliness.  It  is  harmful  when  it  exhausts  the  patient;  and  inasmuch  as 
exhaustion  occurs  so  readily  in  this  disease  local  treatment  must  be 
employed  with  great  discrimination.  The  chief  object  is  that  of  cleans- 
ing. For  this  purpose  douching  of  the  nose  and  throat  with  warm 
alkaline  antiseptic  solutions,  such  as  a  diluted  liquor  sodii  boratis  comp. 
(Dobell's  solution)  may  be  employed,  or  a  normal  salt  or  a  1  or  2  per  cent, 
boric  acid  solution.  The  injection  is  preferably  given  with  a  fountain- 
syringe  or  a  soft  rubber  nasal  syringe  (p.  238,  Fig.  38).  The  child  should 
lie  well  on  one  side  and  the  fluid,  if  used  in  the  nose,  be  made  to  enter 
the  upper  nostril  and  flow  from  the  other.  In  some  cases  an  atomizer 
may  well  be  employed,  but  the  syringe  is  generally  more  elTective.  Local 
treatment  every  3  or  4  hours  is  enough  in  mild  cases,  and  in  severe  ones 
every  2  hours.  Spraying  or  swabbing  the  throat  with  a  much  diluted  and 
non-acid  solution  of  peroxide  of  hydrogen  is  often  efficacious  in  dissolving 
the  membrane.     Application  of  solutions  of  more  powerful  drugs,  such 

1  Arch.  Int.  Med.,  1916,  XVII,  170. 

30 


466  THE  DISEASES  OF  CHILDREN 

as  preparations  of  iron,  nitrate  of  silver,  and  the  like,  have  largely  gone 
out  of  vogue.  They  are  usually  painful  and  cause  distress  to  and  re- 
sistance by  the  patient.  An  ice-bag  applied  externally  over  the  position 
of  the  tonsils,  and  small  pieces  of  ice  placed  frequently  in  the  mouth,  tend 
to  relieve  the  pain  and  difficulty  in  swallowing. 

Extension  of  the  disease  to  the  larynx  is  largelj^  prevented  by  the 
early  and  free  use  of  antitoxin.  When,  however,  laryngeal  symptoms 
are  threatening,  the  use  of  the  croup-tent  (p.  236)  is  often  of  great 
benefit.  The  patient  should,  however,  not  be  kept  in  the  tent  over  20 
or  30  minutes  at  one  time,  as  the  effect  may  be  depressing  or  the  amount  of 
oxygen  too  greatly  diminished.  Sometimes  allowing  a  stream  of  oxygen 
to  enter  the  tent  at  the  same  time  with  the  vapor  is  of  benefit. 

Operative  Treatment. — When  cyanosis  is  clearly  increasing  in  laryn- 
geal cases,  stenosis  is  decided,  and  the  accessory  muscles  of  respiration  in 
full  play,  prompt  operative  measures  are  indicated,  and  it  is  important 
that  they  be  not  unduly  delayed.  These  consist  respectively  in  tracheo- 
tomy and  in  intubation.  The  latter  has  largely  supplanted  the  former  in 
most  countries.  Tracheotomy,  however,  may  quickly  become  necessary 
after  intubation  if  no  relief  is  obtained. 

The  technique  of  tracheotomy  is  so  strictly  surgical  that  no  attempt 
will  be  made  to  describe  it  in  this  connection.  The  after-treatment  of 
tracheotomy  consists  principally  in  keeping  the  tube  clean  of  mucus  and 
pseudomembrane,  and  in  maintaining  the  air  saturated'  with  warm 
water-vapor  produced  by  the  boiling  of  water,  the  slaking  of  lime,  the 
plunging  of  hot  iron  into  water,  or  in  other  ways. 

Intubation. — This  was  first  successfully  put  into  practice  by  O'Dwyer^ 
and  has  been  the  means  of  saving  inany  lives.  Inasmuch  as  favorable 
results  depend  to  a  large  extent  on  the  skill  and  training  of  the  operator, 
I  append  the  following  description  kindly  prepared  for  me  by  Dr.  Henry  R. 
Wharton,  Senior  Surgeon  to  the  Children's  Hospital  of  Philadelphia. 

''Instruments  Required  for  Intubation. — The  instruments  required  for 
intubation  are  intubation  tubes,  and  an  apparatus  to  insert  them.  The 
tubes  for  children  are  usually  six  in  number,  of  different  sizes  adapted 
to  the  age  of  from  1  to  12  years.  The  sort  now  generally  employed 
consists  of  a  metalhc  cylinder  which  bulges  near  its  center,  with  a  collar 
or  head  to  rest  upon  the  vocal  cords.  The  tubes  are  gold  plated  or  of  hard 
rubber  with  a  metallic  lining,  and  are  provided  with  an  obturator  which 
has  a  blunt  extremity;  and  through  the  edge  of  the  collar  on  each  tube 
there  is  a  small  perforation  into  which  a  strand  of  fine  braided  silk  is 
passed.  This  serves  to  remove  the  tube,  if  in  its  introduction  it  should 
have  been  passed  into  the  pharynx  or  the  esophagus  instead  of  the  larynx, 
or  if  it  has  to  be  hurriedly  withdrawn,  owing  to  sudden  obstruction  of 
breathing. 

"  The  Introducer. — This  instrument  consists  of  a  handle  and  a  staff, 
bent  to  a  right  angle  at  its  extremity,  having  a  screw  that  attaches  it  to 
the  obturator,  and  a  sliding  gear  for  detaching  the  obturator  from  the 
tube  when  it  is  placed  in  the  larynx  (Fig.  142). 

"  Mouth-gags. — Mouth-gags  of  various  kinds  may  be  employed.  The 
one  generally  used  is  a  self-retaining  instrument  (Fig.  142),  and  the 
portion  inserted  between  the  teeth  is  covered  by  pieces  of  rubber-tubing 
to  prevent  injury. 

''Extractor. — The  extractor  is  also  bent  at  a  right  angle  and  has  at  its 
extremity  a  small  forceps  with  duck-bill  blades  which  are  made  to  sepa- 
1  N.  Y.  Med.  Journ.,  1885,  XLII,  145. 


DIPHTHERIA 


467 


rate  and  apply  themselves  to  the  inner  surfaces  of  the  tube  with  sufficient 
firmness  to  withdraw  it  (Fig.  142). 

^^Preparations  for  Intubation. — It  should  not  be  forgotten  that  when  an 
intubation  tube  enters  the  larynx  breathing  is  arrested  until  the  obturator 
is  removed,  and  therefore  the  manipulations  should  be  as  rapid  as  is 
consistent  with  accuracy.  The  surgeon  should  select  a  tube  of  suitable 
size  for  the  age  of  the  patient,  pass  a  strand  of  fine  braided  silk  about  2 
feet  in  length  through  the  opening  in  the  collar  of  the  tube,  and  knot 
the  ends  together.  The  tube  is  then  attached  by  means  of  the  obturator 
to  the  introducer.  To  prevent  the  patient  from  biting  the  finger,  in  case 
the  mouth-gag  should  slip,  the  surgeon  should  protect  the  index-finger  of 


Fig.   142. — O'Dwyer's  Intubation  lNSTKr.MENTS. 
A,  Tube  with  obturator;  B,  tube;  C,  obturator;  D,  metal  gage;  E,  mouth-gag;  F,  in- 
troducer; G,  extractor;  H,  silk  cord.      (Fowler.) 


the  left  hand  in  the  region  of  the  second  joint  by  wrapping  it  with  a 
piece  of  rubber  plaster,  or  by  slipping  over  it  a  metal  shield. 

^'Operation. — -This  maybe  performed  while  the  child  is  in  the  sitting 
posture,  or  while  it  is  recumbent.  The  former  position  I  prefer.  The 
child  should  be  placed  upon  the  lap  of  the  nurse  or  assistant,  and  covered 
by  a  blanket  loosely  thrown  around  it.  The  nurse  grasps  the  child's 
elbows  from  outside  of  the  blanket  and  holds  them  firmly,  but  should  not 
press  them  against  the  chest  in  such  a  way  as  to  embarrass  the  respiratory 
movements.  At  the  same  time  the  legs  of  the  patient  should  be  secured 
by  l)eing  held  between  the  knees  of  tlie  nurse.  The  head  of  the  patient 
is  held  firmly  between  the  open  hands  of  the  assistant,  placed  on  either 
side  of  the  head  and  cheeks.  The  left  hand  of  the  assistant  may  also  be 
used  to  steady  the  mouth-gag  after  it  has  been  introduced  (Fig.    143). 


468 


THE  DISEASES  OF  CHILDREN 


As  before  stated,  the  tube  may  be  introduced  with  the  child  in  the  recum- 
bent^^posture.  This  I  have  done  when,  from  the  condition  of  the  circu- 
lation, I  did  not  think  it  advisable  to  lift  the  patient  to  the  sitting  posture. 
The  mouth  is  opened  and  the  blades  of  the  mouth-gag  introduced  between 
the  molar  teeth  upon  the  left  side,  and  the  jaws  opened  by  this  as  widely 
as  possible.     The  surgeon  next  passes  the  index-finger  of  the  left  hand  into 


Fig.   143. — LNTri'.AiiD.v.     Inserting  the  Ti'be. 
(Wharton,  Starr's  Amer.  Text-book  of  Diseases  of  Children,  1894,  314.) 


the  pharynx  and  feels  for  the  epiglottis,  hooking  this  forward  by  the  end 
of  the  finger.  The  tube  attached  to  the  introducer  held  in  the  right  hand 
is  next  passed  into  the  mouth  and  carried  back  to  the  pharynx,  the  opera- 
tor being  careful  to  see  that  it  hugs  the  base  of  the  tongue  in  the  middle 
line,  that  the  handle  is  depressed  well  upon  the  child's  chest,  and  that  the 
silken  loop  is  free.  When  the  extremity  of  the  tube  comes  in  contact  with 
the  end  of  the  finger  resting  upon  the  epiglottis,  the  handle  of  the  instru- 
ment should  be  raised  as  the  tube  enters  into  the  larynx  and  descends  into 


DIPHTHERIA  469 

that  organ,  and  when  in  position,  the  finger  is  placed  upon  the  head  of  the 
tube  to  prevent  its  being  withdrawn  with  the  obturator.  The  trigger  is 
next  pressed,  and  the  introducer  and  obturator  withdrawn  from  the  mouth 
by  depressing  the  handle  upon  the  chest.  Before  removing  the  finger  it 
is  well  to  push  the  tube  well  into  the  larynx.  As  soon  as  the  obturator 
is  removed  there  is  generally  a  violent  expiratory  effort  with  coughing, 
accompanied  by  a  gush  of  mucopurulent  matter  or  membrane,  and  after 
this  escapes  the  breathing  is  usually  satisfactorily  established.  If  the 
operator  has  passed  the  tube  into  the  pharynx  or  esophagus,  no  improve- 
ment in  the  respiration  takes  place,  and  it  should  then  be  withdrawn 
by  the  silken  loop  and  another  attempt  made  to  introduce  it  correctly. 
The  mistake  which  inexperienced  operators  make  in  attempting  to  intro- 
duce the  intubation  tube  consists  in  not  hugging  the  posterior  surface  of 
the  tongue  closely,  as  a  result  of  which  the  tube  passes  over  the  epiglottis 
into  the  pharynx.  The  most  serious  complication  which  is  apt  to  occur 
during  the  introduction  is  in  the  pushing  of  a  mass  of  membrane  in  front 
of  the  tube  into  the  trachea.  If  this  is  too  large  to  be  expelled  through 
the  tube,  the  breathing  is  suddenly  arrested.  The  tube  should  then  be 
removed  at  once,  and  if  the  mass  of  membrane  does  not  escape  upon  the 
expiratory  efforts  of  the  patient,  the  trachea  should  be  rapidly  opened. 
So  much  do  I  dread  this  accident,  which  has  occurred  to  me  in  one  case 
only,  that  I  never  introduce  an  intubation  tube  without  having  at  hand 
the  necessary  instruments  for  a  rapid  tracheotomy. 

"  Another  accident  which  is  said  to  have  occurred,  of  which  I  have  no 
personal  experience,  is  the  pushing  of  the  intubation  tube  through  the 
wall  of  the  larynx  into  the  cellular  tissue.  This  is  not  likely  to  happen 
unless  undue  force  has  been  used.  The  production  of  a  false  passage  is 
recognized  by  the  fact  that,  although  the  tip  of  the  tube  can  be  felt  to 
enter  the  larynx,  it  does  not  descend,  but  projects  above  the  epiglottis. 
Some  operators  keep  the  silken  loop  attached  to  the  tube  during  the  time 
it  is  retained  in  the  larynx,  so  that  by  drawing  upon  it  the  nurse  or  attend- 
ant is  able  to  withdraw  the  tube  instantly  if  it  should  become  obstructed 
with  membrane,  or  be  coughed  up  and  pass  into  the  pharynx  or  esophagus. 
I  generally  allow  the  loop  to  remain  in  place  for  10  or  15  minutes.  At  the 
end  of  this  time  I  introduce  the  finger  into  the  mouth  and  feel  that 
the  tube  is  in  its  proper  place,  and  while  the  tip  of  the  finger  rests  upon  the 
edge  of  the  tube,  divide  the  silk  loop  and  withdraw  it. 

^'After-Treatment. — After  intubation,  so  far  as  the  tube  itself  is  con- 
cerned, no  treatment  is  required.  The  patient  should  be  kept  in  a  warm 
room  in  which  a  certain  amount  of  moisture  is  maintained  by  the  use  of 
boiling  water  or  by  a  steam  spray.  If  there  is  but  little  tendency  to 
expectoration  through  the  tube,  soda  solution,  which  consists  of  carbonate 
of  soda,  1  to  2  dr.  (3.9  to  7.8) ;  glycerine,  1  fl.oz.  (30) ;  and  water,  G  fi.oz.  (177) 
applied  by  means  of  a  steam  atomizer,  maj--  be  used  with  advantage.  One 
of  the  greatest  troubles  after  intubation  of  the  larynx  is  the  satisfactory 
feeding  of  the  patient  and  the  administration  of  liquid  medicines.  Liq- 
uids, as  a  rule,  arc  not  swallowed  well,  a  portion  of  them  passing  into  the 
tube  and  producing  violent  coughing.  Cases  are,  however,  occasionally 
met  with  in  which  the  swallowing  of  liquids  does  not  seem  to  l)e  specially 
interfered  with  by  the  presence  of  the  intul)ation  tube.  Nursing  infants 
may  sometimes  continue  at  the  breast  after  the  operation.  I  usually  order 
a  diet  of  semisolids,  such  as  corn-starch,  soft  boiled  eggs,  mush,  and  junket. 
The  taking  of  a  sufficient  cjuantity  of  water  often  causes  trouble,  and  in 
such  cases  the  child  may  be  allowetl  to  swallow  small  pieces  of  ice,  or 


470 


THE  DISEASES  OF  CHILDREN 


water  may  be  regularh-  administered  by  the  rectum.  In  cases  where  there 
is  difficulty  in  swallowing  even  this  form  of  diet,  it  may  be  necessary  to 
resort  to  introduction  of  liquids  into  the  stomach  by  means  of  a  feeding- 
tube  passed  through  the  nostril  into  the  esophagus.  In  young  patients 
in  whom  a  liquid  or  milk  diet  is  essential,  if  the  head  is  dropped  a  little 


Fig.   144. —  Method  of  1'ekdi.ng  Infant  After  Intimation,   with   the    Head  Lower 

THAN  THE  BoDY. 

(Wharton,  Starr's  Amer.  Text-book  of  Diseases  of  Children,  1894,  316.) 


lower  than  the  body  during  the  act  of  deglutition  it  will  often  be  found 
that  fluids  are  swallowed  without  difficulty  (Fig.  144). 

'  ■  Removal  of  Intubation  Tubes. — The  intubation  tube  usually  remains  in 
place  about  a  week.  I  usually  remove  it  within  3  or  4  days,  and  if  the 
breathing  is  satisfactorily  carried  on  for  half  an  hour,  and  no  dyspnea 
appears,  its  reintroduction  may  not  be  necessary.  If,  however,  after  it 
has  been  out  a  few  minutes,  dyspnea  returns,  it  should  be  promptly 


DIPHTHERIA  471 

reintroduced  and  its  removal  should  not  be  attempted  for  3  or  4 
days.  In  many  cases  the  tube  is  coughed  out  within  a  week  from  its 
introduction,  and  its  reintroduction  is  not  often  required  in  these 
cases.  It  can  usually  be  permanently  dispensed  with  in  from  5  to  10 
days,  although  I  have  had  cases  in  which  it  could  not  be  permanently 
removed  until  the  15th  day.  Cases  have  been  reported  in  which  it  had 
to  be  worn  for  many  months.  After  an  intubation  tube  had  been  coughed 
up  or  removed,  the  patient  should  be  carefully  watched  from  12  to  24 
hours,  for  the  dyspnea  may  return  at  any  time  within  this  period  and 
require  replacement  of  the  tube.  The  intubation  tube  may  be  coughed 
up  and  swallowed,  entering  the  stomach.  This  accident  need  cause  no 
anxiety,  as  in  my  experience  these  tubes  usually  pass  safely  through  the 
intestines.  After  intubation  of  the  larynx  very  decided  hoarseness  often 
persists  for  several  weeks,  but  after  this  time  usually  entirely  passes  away. 

' '  Retaiyied  Intubation  Tubes. — If  an  intubation  tube  has  been  worn 
for  a  long  time  there  is  sometimes  great  difficulty  in  removing  it  perma- 
nently. Its  removal  may  often  be  accomplished  by  introducing  at  inter- 
vals tubes  of  gradually  increasing  size." 

Treatment  of  Complications  and  Sequels  and  of  the  Convalescence. — 
The  exhaustion  and  cardiac  weakness  following  severe  cases  of  diphtheria 
require  especial  attention.  Rest  in  bed  in  the  recumbent  position  must 
continue  so  long  as  there  are  any  evidences  of  decided  weakness  of  the 
heart,  shown  by  rapidity,  irregularity,  or  slowness  of  the  pulse,  or  by 
weak  heart-sounds.  Excitement  and  physical  exertion  of  all  sorts  must 
be  carefully  avoided.  Even  after  mild  attacks  the  patient  should  be 
kept  in  bed  for  at  least  a  week  after  the  membrane  has  disappeared  and 
only  cautiously  allowed  to  sit  upright,  although  the  heart  may  appear  to 
be  entirely  normal.  General  tonic  treatment  is  indicated,  especially 
with  alcohol,  strychnine  and  sometimes  digitalis.  Adrenalin  chloride 
(1  :  1000)  has  been  used  to  prevent  cardiac  failure,  the  dose  being  5  to  10 
m.  (0.31  to  0.616)  according  to  age.  Pituitrin  has  also  been  used  with 
success. 

The  anemia  which  often  remains  demands  a  long  course  of  iron  or 
arsenic  with  abundant  nourishment.  Frequently  cod-liver  oil  is  of 
benefit,  and  the  continued  use  of  alcoholic  stimulants  may  be  needed. 
Nephritis  remaining  as  a  sequel  requires  treatment  appropriate  to  it. 
It  may  necessitate  a  continuance  of  liquid  diet,  especially  milk,  longer 
than  one  would  wish  in  view  of  the  importance  of  nourishment  from  other 
points  of  view. 

The  treatment  of  post-diphtheritic  paralysis  depends  to  some  extent 
upon  the  part  affected.  Paralysis  of  the  extremities  is  to  be  aided  by 
massage.  That  of  the  muscles  of  deglutition  may  occasionally  require 
feeding  by  gavage,  but  this  is  uncommon.  In  any  form  of  paralysis  the 
chief  aid  is  to  be  sought  in  electricity  and  the  free  use  of  strychnine  com- 
bined with  abtnidaiit  nourishment. 

Treatment  of  Carriers. — Finally,  there  is  often  difficuHy  in  ridding 
tiie  jiatient  of  the  Klcbs-Loffler  bacilli  which  may  persist  long  after  all 
symptoms  have  disappeared,  the  intlividual  thus  becoming  a  carrier. 
The  treatment  is  the  same  for  healthy  individuals  who  have  not  had  the 
disease,  but  who  have  been  proven  to  be  dangerous  carriers.  The  diffi- 
culty in  getting  rid  of  the  bacilli  in  these  cases  is  often  very  great.  This 
is  doul)tless  because  in  many  instances  they  may  remain  indefinitely  in 
the  crypts  of  the  tonsils  or  adenoid  growths  or  in  the  nasal  sinuses. 
Various  measures  have  been  recommended.     A  very  weak  (1  :  10,000) 


472  THE  DISEASES  OF  CHILDREN 

solution  of  bichloride  of  mercury  may  be  employed  by  syringing  the 
nose  or  as  a  gargle;  or  a  weak  solution  of  boric  acid  or  of  liquor  sodii 
boratis  comp.  may  be  used.  Hand  ^  applied  with  success  a  strong  solution 
of  nitrate  of  silver  (60  gr.:  1  fi.oz.)  (4:30)  to  the  throat.  Many  report 
success  with  the  spraying  of  the  nose  and  throat  several  times  daily  with 
a  boullion-culture  of  the  staphylococcus  pyogenes  aureus,  as  first 
recommended  by  Schiotz.^  A  rapid  disappearance  of  the  diphtheria- 
bacilli  may  occur,  these  being  crowded  out  by  the  other  germs.  (See 
articles  by  Lorenz  and  Ravenel,^  Rolleston,'*  Lake''  and  others.)  Good 
results  have  also  been  claimed  from  the  application  of  cultures  of  lactic 
acid  bacilli  applied  in  a  similar  manner  (Nicholson  and  Hogan)  .*'  Vaccine 
treatment  with  killed  diphtheria  bacilli  has  also  been  recommended,  but 
the  results  as  reported  by  Park  and  Zingher^  have  been  disappointing. 
In  every  case  of  persistence  of  the  bacilli  an  inoculation  test  in  guinea- 
pigs  should  be  made.  If  the  germs  are  proven  to  be  non-virulent,  quaran- 
tine is  no  longer  necessary.  In  other  cases  of  unusually  long  persistence 
of  virulent  bacilli,  often  the  best  means  of  treatment  is  the  removal  of 
the  tonsils  and  adenoids. 


CHAPTER  XIII 
GRIPPE 

(Influenza) 


Grippe,  or  influenza,  was  described  clearly  in  the  12th  century,  and 
its  epidemic,  infectious  character  recognized  since  the  16th  century. 
It  first  appeared  in  the  United  States  in  1627.  Whether  the  cases  ob- 
served in  these  earlier  widespread  epidemics  were  etiologically  identical 
in  nature  with  those  which  have  been  encountered  in  more  recent  years 
cannot  be  positively  determined ;  but  from  a  clinical  point  of  view  no  sharp 
distinction  can  be  drawn.  From  a  bacteriological  standpoint  a  distinc- 
tion may,  it  is  true,  be  made,  and  it  is  to  those  depending  upon  the 
influenza  bacillus  that  the  title  "influenza  vera"  has  been  applied,  others 
resembling  these  clinically  but  being  produced  by  other  germs  having 
been  called  pseudo-influenza,  or  "influenza  nostras."  It  has  also  been 
proposed  to  designate  as  influenza  all  the  diseases  depending  upon  the 
influenza  bacillus;  a  course  very  similar  to  that  resulting  should  we  call 
"pneumonia"  all  lesions  produced  by  the  pneumococcus.  It  seems  best, 
therefore,  to  class  together  all  those  cases  showing  symptoms  which  have 
usually  been  regarded  as  evidences  of  grippe  or  of  influenza  respectively, 
and  in  which  no  sharp  clinical  distinction  can  be  made,  and  to  designate 
these  "grippe,"  whatever  the  active  germ  may  be.  Certainly  the  rnere 
existence  of  symptoms  of  a  severe  febiile  cold  does  not  warrant  the  diag- 
nosis of  grippe.  Certainly,  too,  the  epidemic  contagious  condition  to 
which  the  title  "grippe"  is  applied  is  as  often  dependent  upon  other  germs 

1  Phila.  Med.  Journ.,  1898,  Aug.  24. 

==  Ugeskr.  f.  Lager.  1909,  LXXI,  No.  49.     Ref.  Journ.  Amer.  Med.  Assoc,  1910, 
LIV,  442. 

3  Journ.  Amer.  Med.  Assoc,  1912,  LIX,  690. 
*  Brit.  Journ.  Child.  Dis.,  1913,  X,  298. 
5  New  York  Med.  Rec,  1912,  LXXXI,  1228. 
8  Journ.  Amer.  Med.  Assoc,  1914,  LXII,  510. 
^  Loc.  cit. 


GRIPPE  473 

as  upon  the  influenza  bacillus.  The  subject  of  grippe  in  early  life  has 
been  exhaustively  studied  by  RiseP  with  extensive  bibliography. 

Etiology.  Predisposing  Causes. — Climate,  race,  locality,  sex,  and 
social  conditions,  exert  no  influence.  The  previous  health  is  also  not  a 
factor,  except  that  affections  of  the  respiratory  tract  increase  the  sus- 
ceptibility. Consequently  all  causes  are  important  which  render  the 
mucous  membrane  of  the  respiratory  tract  sensitive,  such  as  bad  weather, 
exposure  to  cold,  insufficient  ventilation,  and  the  like. 

All  periods  of  life  are  susceptible,  and  the  disease  my  occur  even  in 
the  new  born.  Strassman^  observed  8  cases  at  this  period.  InComby's 
statistics^  of  218  cases  in  children,  48  occurred  from  birth  to  2  j^ears,  1 
being  but  17  days  old;  76  at  from  2  to  5  years,  and  94  at  from  5  to  15 
years.  The  epidemic  character  is  more  marked  than  perhaps  in  any  other 
affection.  The  disease  at  first  occurred  in  epidemics,  generally  wide- 
spread and  separated  by  decades.  The  great  epidemic  of  1889  appeared 
first  in  Turkestan  after  an  interval  of  many  years,  and  extended 
rapidly  over  the  greater  part  of  the  earth.  In  less  than  6  months  it 
had  reached  the  United  States.  In  1890-91  there  was  another  serious 
outbreak  most  marked  in  England  and  America.  The  disease  then 
became  endemic  to  a  limited  extent,  with  occasional  larger  and  more 
wide-spread  outbreaks,  at  first  regardless  of  season,  but  later  usually  in 
the  cooler  months  of  the  year;  until  the  greatest  and  most  serious  epidemic 
of  it  ever  experienced,  which  occurred  in  1918.  This  apparently  arose  in 
the  Orient*  and  spread  rapidly  over  Europe  and  America,  millions  of 
individuals  being  attacked.  Of  the  cities  of  the  United  States,  Phila- 
delphia suffered  very  heavily,  about  150,000  cases  having  occurred  in  the 
course  of  2i/^  months.^  The  individual  susceptihility  is  extreme,  the  large 
majority  of  persons  exposed  contracting  the  disease.  This  was  especially 
true  in  the  epidemic  of  1889-90  and  of  1918.  In  the  last  epidemic  chil- 
dren were  somewhat  less  frequently  and  decidedly  less  severely  attacked 
than  adults. 

Exciting  Cause. — The  disease  is  a  distinctly  infectious  one.  The 
investigations  of  Pfeiffer^  revealed  an  extremely  small,  non-motile  bacillus 
in  the  sputum  and  the  nasal  secretion,  at  first  free  in  the  mucus  and  later 
in  the  pus  cells.  It  is  less  often  present  in  the  blood  and  it  has  been 
recovered  from  the  cerebrospinal  fluid  by  lumbar  puncture.  It  generally 
disappears  with  the  return  of  health,  and  it  lives  outside  of  the  body  in 
infected  nasal  or  bronchial  mucus  for  only  about  14  days.  Exceptions 
occur,  however,  and  in  more  chronic  cases  or  even  in  those  entirely 
convalescent  it  can  sometimes  be  found  in  the  secretions  or  in  the  pus  of 
complicating  conditions  even  for  months.  According  to  Lord^  it  could 
be  discovered  in  the  sputum  years  after  recovery  from  the  disease. 
Although  the  influenza  bacillus  appears  to  have  been  that  most  frequently 
present  in  the  early  epidemics,  as  time  passed  it  was  more  and  more 
replaced  by  other  germs,  and  up  to  the  year  1918  this  bacillus  could  not  be 
found  in  the  large  majority  of  cases.  In  the  1918  epidomic  the  opinions 
regarding  the  exciting  cause  were  most  divergent;  in  some  regions  the 
influenza  bacillus  being  reported  in  the  majority  of  cases;  in  others 

1  ErRebn.  der  inn.  Med.  u.  Kinderh.,  1912,  VIII,  211. 

2  Zeitschr.  f.  Gcburtsh.  u.  Gvn.,  1890,  XIX,  39. 

3  Bull,  do  la  sor.  dos  hop.,  l.S<)(),  VII,  ()7. 

<  U.  S.  ruhi.  Health  Scivicc,  191S.  Suppl.  Xo.  34,  Sept.  2S. 

8  Monthly  HiiUctiii,  Dcpt.  of  Health,  191S,  111,  No.  10-11,  23. 

•  Deut.  incd.  Wocli.,  1892,  XVllI,  28;  Zeit.schr.  f.  Hyg.,  1893,  XIII,  367. 

'  Best.  Med.  and  Surg.  Journ.,  190.5,  CLII,  537. 


474  THE  DISEASES  OF  CHILDREN 

its  occurrence  being  comparative!}^  uncommon  and  other  organisms  of 
various  sorts  being  apparently  the  agents.  Among  the  other  germs 
recorded  are  the  micrococcus  catarrhahs,  pneumococcus,  staphylococcus, 
bacillus  mucosus  capsulatus,  streptococcus  mucosus  capsulatus,  strepto- 
coccus hsemolyticus,  cliplococcus  mucosus  and  pneumococcus  mucosus. 
These  germs  may  occur  in  practically  pure  culture  or  often  associated  in 
various  ways.  Yet  it  is  uncertain  whether  any  of  them  are  the  actual 
cause  of  grippe,  and  whether  the  symptoms  are  not  produced  by  a  micro- 
organism still  undiscovered. 

Grippe  is  very  contagious.  In  the  large  majority  of  instances  trans- 
mission is  direct  through  the  infectious  secretion  from  the  respiratory 
tract.  Usually  an  outbreak  among  the  children  of  a  family  arises 
from  one  of  the  adult  members  sick  with  the  disease.  The  air  may  also 
spread  the  disease  by  disseminating  the  dried  infected  mucus,  but  probably 
only  to  a  limited  distance.  Indirect  transmission  by  a  third  healthy 
person  or  by  clothing,  and  the  like,  is  of  doubtful  occurrence.  The 
entrance  of  the  germs  into  the  body  is  by  way  of  the  respiratory  tract. 

Pathological  Anatomy. — Apart  from  the  presence  of  a  catarrhal 
condition  of  the  respiratory  and  alimentary  mucous  membranes  the 
lesions  are  those  only  of  the  complications  which  may  arise. 

Symptoms. — The  clinical  manifestations  are  most  varied.  We  may, 
however,  recognize  a  typical  form  of  grippe,  and  a  number  of  ■modified 
forms,  marked  by  the  predominance  of  certain  groups  of  symptoms. 
Some  one  or  another  of  the  variations  has  oftener  been  witnessed  than 
the  type  itself.  In  the  epidemic  of  1918,  however,  there  was  less  varia- 
tion seen  than  in  preceding  ones. 

Typical  Form.  Incubation, — This  is  short,  lasting  from  1  to  3  days 
and  is  generally  unattended  by  symptoms.  Occasionally  malaise,  irrita- 
bility, vague  pains  and  loss  of  appetite  are  witnessed. 

Symptoms  of  the  Attack. — In  typical  grippe  there  is  exhibited  a  fair 
balance  between  the  various  groups  of  symptoms  which  characterize  the 
different  varieties.  The  onset  is  usually  sudden,  with  chilliness,  high 
fever  and  sometimes  convulsions.  In  older  children  pain  in  the  limbs, 
trunk  and  head  may  be  complained  of;  in  younger  ones  there  is  clearly 
discomfort,  the  nature  of  which  cannot  h^  determined.  The  temperature 
does  not  remain  persistently  high,  but  runs  an  irregular  and  characteristic 
course,  varying  from  100°  to  105°F.  (37.8°  to40.6°C.)  and  falling  by  lysis 
or  crisis  in  3  to  4  days  (Fig.  145).  The  respiration  and  pulse  are  acceler- 
ated in  proportion  to  the  temperature.  Vomiting  sometimes  occurs  and 
may  be  obstinate;  diarrhea  may  develop;  loss  of  appetite  is  marked. 
Prostration,  out  of  proportion  to  the  other  symptoms,  is  one  of  the  most 
characteristic  manifestations.  A  varying  degree  of  inflammation  of 
the  nose  and  throat  and  less  often  of  the  trachea  and  bronchi  is  present, 
yet  not  of  a  nature  sufficient  to  account  for  the  general  symptoms. 
Albuminuria  is  seen  in  a  small  proportion  of  cases;  leucocytosis  is  some- 
times present,  oftener  absent;  enlargement  of  the  spleen  is  not  infrequently 
discoverable.  In  the  1918  epidemic  leucopenia  was  a  very  characteristic 
feature.  The  duration  of  the  acute  attack  is  generally  only  from  3 
to  5  days,  but  decided  debility,  anorexia  and  often  neuralgic  pain  may 
remain  for  several  weeks.  The  symptoms  in  early  life  are  generally 
not  so  severe  as  in  adults,  but  to  this  there  are  numerous  exceptions. 

This  ordinary  type  may  be  either  viild  or  severe,  and  between  the  two 
extremes  all  grades  of  severity  are  seen.  In  the  mild  cases  local  manifesta- 
tions may  be  entirely  absent  and  there  may  be  only  a  very  moderate 


GRIPPE 


475 


degree  of  prostration  with  slight  fever  (Fig.  146).  The  child  may  not 
feel  ill  enough  to  go  to  bed,  and  in  a  day  or  two  is  entirely  convalescent. 
This  is  a  form  quite  common  in  early  life.  In  the  severe  cases  the  tem- 
perature may  be  high  or  only  slightly  elevated,  but  in  any  event  it  runs 
no  regular  course  and  is  uncharacteristic.  The  prostration  is  very 
decided,  appetite  is  completely  lost  and  some  of  the  locaUzing  symptoms 
may  be  marked.  Sometimes  the  course  is  protracted  for  weeks  or  even 
months,  with  debihty  and  in  older  children  more  or  less  pain.  In 
infants  especially  the  attack  may  be  very  severe,  vomitmg  troublesome, 


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Fig.   145. — Grippe,  Typical  Form. 
Anna  S.,  aged  10  mouths.     Cough,  running  eyes,  fever,  debility,  frequent  loose  stools, 
vomited  once.     Slight  preponderance  of  gastrointestinal  symptoms.     Epidemic  prevailing. 

Fig.  146. — Grippe,  Typical  Form,  Mild. 
Hannah    E.,    aged   4j^    years.     Vomited   occasionally,    headache,  slight  sore   throat, 
loose  cough,  no  marked  prostration.     Child  bright  and  very  little  ill.     Epidemic  prevailing. 


loss  of  appetite  absolute,  prostration  very  great,  and  respiration  rapid. 
The  patient  may  seem  to  be  overwhelmed  by  the  poison  of  the  disease 
without  any  evidence  of  local  lesions  and  collapse  may  follow.  The 
severe  cases  last  from  a  few  days  up  to  2  or  more  weeks,  and  convalescence 
is  very  tedious  (Fig.  147). 

The  (lificrent  variants  from  typical  grippe  depentl  on  the  prominence 
of  symptoms  of  a  certain  class,  and  the  lesser  development  of  those  of 
other  classes.  Not  infrequently  the  symptoms  of  two  or  more  classes 
may  be  equally  prominent.  As  a  rule  the  nervous  and  gastrointestinal 
forms  of  grippe  are  most  frequent  in  infancy  and  early  childhood.  The 
respiratory  is  that  most  often  seen  in  later  childiiood.     Yet  to  this  there 


476 


THE  DISEASES  OF  CHILDREN 


are  numerous  exceptions,  and  all  sorts  of  combinations  of  symptoms  of 
the  different  forms  may  be  seen. 

Catarrhal  or  Respiratory  Form.— In  this  form  coryza  is  decided, 
the  pharynx  is  red,  the  tonsils  swollen  with  the  follicles  sometimes 
engorged;  stomatitis  may  occur;  there  is  annoying  cough  depending 
upon  involvement  of  the  larynx,  trachea  and  bronchi;  and  fever  and 
prostration  are  present  to  a  degree  in  no  way  explained  by  the  local 
manifestations  (Fig.  148).  The  severity  of  the  attack  generally  dimin- 
ishes in  3  or  4  days.     In  severe  cases  of  this  type  the  course  is  longer 


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Fig.  148. 


Fig.  147. — Grippe,  Severe  Respiratory  Type. 
William  McC,  aged  11  months.  Feb.  19,  for  some  days  cold  in  head  and  moderate 
bronchitis,  no  fever;  Feb.  21,  temperature  rose  in  afternoon,  croupy  cough;  Feb.  22, 
cyanosis;  Feb.  23,  many  rales,  with  cyanosis  and  oppression  suggesting  asthmatic  bron- 
chitis; Feb.  15,  seems  very  ill,  cyanosis  and  rales  continuing;  Feb.  27,  rales  nearly  gone, 
general  condition  improving.     Brother  ill  at  the  same  time  with  grippe. 

Fig.  148. — Respiratory  Form  of  Grippe. 
William  R.,  adult.     Headache,  general  aching,  severe  coryza,  harassing  cough,  con- 
gested frontal  sinuses  requiring  local  treatment,  marked  prostration.     Decided  debility 
as  a  sequel. 

and  the  process  readily  advances  to  the  production  of  bronchopneumonia. 
There  is  also  a  special  tendency  to  the  development  of  otitis  and  of 
cervical  adenitis.  The  catarrhal  type  is  not  often  very  severe  under  the 
age  of  10  years,  and  especially  below  that  of  3  years,  but  even  infants 
will  occasionally  exhibit  it.  (See  Fig.  147.)  Sometimes  the  symptoms  of 
this  form  are  unusual  and  not  sufficient  to  mark  the  disease  except  in 
family  outbreaks.  I  have  seen  adults  affected  by  characteristic  grippe 
and  some  of  the  children  of  the  family  showing  the  symptoms  of  spas- 
modic croup  {laryngeal  form  of  grippe).  In  the  earlier  part  of  the  1918 
epidemic  catarrhal  symptoms,  and  especially  tonsillitis,  were    decidedly 


GRIPPE 


477 


infrequent.     Later,  as  the  severity  of  the  cases  grew  less-marked,  tonsil- 
htis  became  a  very  prominent  feature. 

Nervous  Form. — In  this  variety  the  nervous  manifestations  pre- 
dominate and  the  respiratory  anddigestive  symptoms  are  less  in  evidence 
(Fig.  149).  To  this  class  belong  a  large  number  of  cases  in  quite  early 
life.  There  is  marked  apathy,  prostration  and  loss  of  appetite.  In  some 
cases  hyperpyrexia,  delirium,  stupor  or  convulsions  may  occur,  so  that 
the  case  closely  resembles  meningitis;  in  others  the  symptoms  of  the 
typhoid  state  may  develop.     Still  other  cases  exhibit  marked  prostration 


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Fig.   150. 


Fig.  149. — Grippe,  Nervous  Form. 
Helen  C,  aged  19  months.     Pale,  prostrated,  irregular  respiration,  very  drowsy.     No 
pulmonary  symptoms,  no  diarrhea,  vomited  only  once.     Epidemic  prevailing. 
Fig.  150. — Grippe,  Nervous  Form.     Prolonged  Febrile  Type. 
Louise  F.,  aged  16  months.     Slight  cough,  apathy,  prostration,  without  any  localized 
symptoms.     Fever  continued  a  week  or  more.     Twin  sister  with  same  symptoms.     Case 
suggested  typhoid  fever.     Epidemic  of  grippe  prevailing. 

and  continued  fever,  which,  in  the  absence  of  special  localizing  svmptoms 
at  first  strongly  suggests  typhoid  fever  (febrile  form  of  grippe)  (Fig.  150). 
Occasionally  there  is  severe  dyspnea  of  purely  toxic  origin.  Severe 
cases  may  sometimes  end  fatally,  although  generally  in  the  course  of  a 
few  days  all  the;  alarming  symptoms  ameliorate,  showing  that  they  were 
toxic  and  not  iiiflamiuatory  in  nature.  In  other  instances  actuallesions 
of  the  cerebrospinal  system  develop  as  comi)lications  or  sequels.  (See  In- 
fluenzal Meningitis,  Vol.  II,  p.  325.)  A  very  common  variety  of  the  nervous 
type  of  grippe,  especially  frequent  in  younger  subjects,  is  that  showing 
continued  fever  with  moderate  prostration,  and  few  distinct  local  mani- 
festations. Filatow^  has  reported  cases  of  this  sort  in  which  irregular 
fever  lasted  during  5  months. 

1  Arch.  f.  Kanderheilk. ,   1899,  XXVII,  433. 


478  THE  DISEASES  OF  CHILDREN 

Gastrointestinal  Form. — The  prominent  symptoms  of  this  variety, 
a  common  one  in  infancy,  are  anorexia,  nausea,  vomiting,  abdominal 
pain,  prostration  and  diarrhea,  the  stools  often  containing  mucus  and 
blood.  The  symptoms  are  those  of  a  severe  acute  gastroenteritis. 
The  duration  of  the  attack  may  be  only  3  or  4  days,  but  is  not  infre- 
quentty  protracted.  In  other  cases  the  condition  is  one  resembling 
intestinal  toxemia,  and  there  are  present  the  ordinary  symptoms  of  this, 
with  loss  of  weight,  but  without  diarrhea  or  vomiting.  This  is  a  common 
variety  in  infancy.  The  intestinal  form  was  much  less  frequently  observed 
in  the  1918  epidemic  than  in  earlier  ones. 

Complications  and  Sequels. — One  of  the  most  dangerous  and 
common  complications  is  pneumonia.  It  was  especially  frequent  in  the 
epidemic  of  1918,  there  being  an  incidence  of  about  10  per  cent.  The 
form  is  oftenest  a  bronchopneumonia,  the  areas  being  small  and  often 
giving  no  positive  physical  signs.  Less  often  it  is  croupous  in  nature.  The 
pneumonia  of  grippe  develops  either  during  the  attack  or  as  a  sequel. 
The  course  is  irregular,  the  symptoms  being  often  masked  and  much 
more  severe  than  accounted  for  by  the  physical  signs,  and  the  disease 
frequently  of  the  wandering  type  and  much  prolonged.  In  many  other 
cases  it  is  abortive  and  lasts  only  2  or  3  days.  One  of  the  characteristics 
of  the  pneumonia  in  the  last  epidemic  was  the  tendency  often  seen  for 
the  respiration  to  exhibit  little  acceleration;  and  especially  the  persistence 
of  leucopenia  in  spite  of  the  presence  of  the  pneumonic  inflammation. 
(Fig.  151).  Pleurisy  not  infrequently  accompanies  the  pneumonia 
and  tends  to  result  in  empyema.  Bronchitis,  constantly  present  in  the 
respiratory  type  of  influenza,  may  be  severe  enough  to  constitute  an 
important  complication,  especially  in  j^oung  children.  It  then  involves 
the  smaller  tubules  and  produces  dyspnea  and  cyanosis.  Spasmodic 
croup  is  a  complication  sometimes  seen. 

Otitis,  purulent  or  catarrhal,  or  often  hemorrhagic  is  a  frequent 
complication  especially  of  the  respiratory  form  of  grippe.  Either  resolu- 
tion or  perforation  may  occur.  Inflammation  of  the  mastoi'd  cells  may 
follow.  Affections  of  the  eye  are  rarely  observed  except  the  moderate 
conjunctivitis  which  may  properly  be  called  a  symptom.  Cervical 
adenitis  is  a  very  striking  and  frequent  complication.  It  is  often  out  of 
proportion  to  the  severity  of  the  attack  and  independent  of  the  presence 
of  affections  of  the  mouth.  Resolution  is  the  rule.  Parotitis  is  some- 
times observed.  Neuritis  of  various  forms  may  develop  as  a  sequel, 
although  infrequently  in  children.  Meningitis  depending  upon  the 
influenza  bacillus  or  other  germs,  may  accompany  the  attack,  or  occur 
without  other  symptoms.  Adams ^  reported  a  case,  and  collected  20 
others  from  literature,  in  which  the  bacillus  of  influenza  was  found  in 
the  cerebrospinal  fluid  or  in  the  meninges.  I  have  seen  several  such 
instances,  in  none  of  which,  however,  could  the  condition  properly  be 
called  a  complication  of  grippe.  (See  Influenzal  Meningitis,  Vol.  II,  p.  325.) 
Mental  disturbances,  spastic  paralysis,  chorea,  encephalitis  and  other 
nervous  affections  exceptionally  follow  grippe.  Nephritis,  cystitis  and 
pyelitis  are  rare.  Miller^  collected  40  recorded  cases  of  acute  hemorrhagic 
nephritis  occurring  as  a  complication.  Only  a  few  of  these  were  in 
children.  Peritonitis  has  been  reported  as  a  complication  or  sequel. 
Ileocolitis  may  develop  in  the  gastrointestinal  form  of  the  disease  and 
icterus  is  sometimes  witnessed.     Anemia,  at  times  severe,  is  a  fiequent 

1  Arch,  of  Pediat.,  1907,  XXIV,  721. 

2  Arch,  of  Pediat.,  1902,  XIX,  1. 


GRIPPE 


479 


sequel.  Cardiac  complications  are  few  in  children,  except  the  tendency 
to  dangerous  collapse  occasionally  observed,  dependent  at  times  on  acute 
cardiac  dilatation.  Cutaneous  complications  are  interesting  and  not 
rare,  especially  herpes,  urticaria  and  erythema,  which  may  be  either 
morbilliform  or  oftener  scarlatiniform. 

Other  infectious  diseases  may  be  associated  with  grippe,  among 
those  reported  being  erysipelas,  mumps,  scarlet  fever,  measles,  pertussis 
and  diphtheria.  The  development  of  tuberculosis  as  a  sequel  is  not 
infrequent. 


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Fig.  151. — Grippe  Followed  by  Pneumonia  with  Leucopenia. 
Theodore  N.,  aged  3  years.  Admitted  Oct.  19th,  1918,  to  the  Children's  Ward  of  the 
Hospital  of  the  University  of  Pennsylvania.  Father  and  mother  and  one  of  the  other 
children  of  the  family  ill  with  grippe.  Child  developed  fever  and  cough  about  a  week 
before  admission.  Examination  showed  fully  developed  signs  of  consolidation,  lower 
part  of  both  lungs;  child  very  toxic  and  debilitated.  Blood  on  Nov.  4th,  showed  7,600 
leucocytes.     Gradual  recovery. 

Fig.  152. — Grippe,  Respiratory  Form  with  Prompt  Relapse. 
Josephine  V.,  aged  6  years.     Feb.  26,  slight  sore  throat,  high  fever;  Feb.  28,  better, 
considerable  cough;  Mar.  1,  apparently  convalescent;  Mar.  2,  throat  painful,  respiration 
accelerated,  cough,  high  fever,  severe  coryza;  Mar.  4,  numerous  rales,  in  other  respects 
better.     Mother  and  brother  ill  with  grippe. 

Relapse  and  Recurrence.— /Jeiapse,  in  the  sense  of  relighting  of 
symptoms  before  the  disease  is  thoroughly  over,  is  exceedingly  common. 
It  develops  a  few  days  after  symptoms  have  subsided,  possibly  after 
the  patient  has  been  taken  into  the  open  air,  and  may  equal  or  exceed  in 
severity  the  primary  attack  (Fig.  152). 

Recurrence  is  common.  Protection  given  by  one  attack  of  grippe 
lasts  only  a  few  weeks  or  months,  sometimes  longer.  The  large  number 
of  individuals  developing  a  second  attack  a  year  or  less  after  the  first  one 


480  THE  DISEASES  OF  CHILDREN 

shows  the  uncertainty  of  immunity.  In  fact,  those  who  have  once 
suffered  appear  often  especially  predisposed  later. 

Prognosis. — The  mortality  of  uncomplicated  grippe  has  been  low, 
statistics  varying  from  0.5  per  cent,  to  somewhat  over  1  per  cent.  Never- 
theless, when  we  consider  the  enormous  frequency  of  the  disease,  the 
actual  number  of  deaths  from  grippe  or  its  complications  has  reached  a 
surprising  figure,  and  this  is  particularly  true  of  infancy.  Thus,  in 
London  alone  from  January,  1890  to  March,  1891,  4740  persons  died 
from  it  (Leichtenstern) .  ^  As  a  rule  there  is  little  danger  in  uncomplicated 
cases  in  previously  healthy  subjects.  The  chief  danger  of  the  disease  lies 
in  the  complications,  especially  gastrointestinal  disorders  and  pneumonia, 
the  latter  being  the  cause  of  the  majority  of  deaths.  In  the  1918  epi- 
demic the  mortality  was  very  high.  In  46  of  the  largest  cities  of  the 
United  States^  with  a  combined  population  of  23,00,000,  the  number  of 
deaths  from  grippe  from  September  9th  to  November  8th  equalled  82,306, 
chiefly  from  pneumonia.  The  normal  number  of  deaths  from  these 
causes  for  the  same  period  would  have  been  about  4000.  In  Phila- 
delphia^ during  7  weeks  of  the  epidemic  12,687  deaths  were  reported  from 
influenza  and  pneumonia;  the  number  of  deaths  from  the  latter  disease  in 
the  previous  year  having  been  only  293.  These  statistics  apply  to  indi- 
viduals of  all  ages.  The  mortality  in  childhood  as  a  whole  was  decidedly 
less  than  later  in  life,  although  in  the  1st  year  there  is  a  greater  tendency 
to  complications,  and  consequently  a  greater  danger  from  the  disesae, 
than  in  the  years  immediately  following. 

Diagnosis.^ — ^This  is  easy  in  typical  cases  during  an  epidemic. 
Under  other  circumstances  it  may  be  difficult  or  impossible.  Pros- 
tration, which  is  present  in  practically  every  case  except  the  very 
mildest,  and  which  is  out  of  proportion  to  any  discoverable  cause, 
is  the  most  important  diagnostic  symptom.  Fever,  too,  not  satisfactorily 
accounted  for  in  any  other  way,  is  another  characteristic,  as  is  the  pain 
in  many  cases.  The  fact  that  the  mucous  membrane  of  more  than  one 
region  is  affected  is  also  suggestive. 

Mild  isolated  cases  of  the  respiratory  type  cannot  be  distinguished 
from  ordinary  catarrh  of  the  respiratory  tract;  the  severer  ones  exhibit 
too  great  prostration  and  fever,  and  in  general  are  more  ill  than  a  simple 
catarrh  explains.  The  presence  of  cervical  adenitis  too,  is  often  suggest- 
ive. Cases  of  the  nervous  type  may  present  cerebrospinal  symptoms 
suggesting  meningitis.  The  diagnosis  is  impossible  at  the  beginning,  but 
rapid  improvement  in  the  course  of  a  few  days,  with  the  development  of 
the  more  ordinary  evidences  of  grippe  make  the  matter  clear.  In  this 
connection  must  be  emphasized  the  necessity  of  caution  in  making  the 
diagnosis  even  of  a  complicating  meningitis,  unless  this  is  done  by  means 
of  lumbar  puncture.  The  protracted  febrile  cases  of  influenza  without 
special  localized  manifestations  may  be  difficult  to  distinguish  from 
typhoid  fever.  The  suddenness  of  the  onset,  the  frequent  presence  of 
catarrhal  symptoms  of  the  nose  and  eyes,  and  the  absence  of  the  typhoid 
serum-reaction  and  of  roseola  aid  in  distinguishing  it.  Enlargement 
of  the  spleen  may  be  present  in  either  disease,  but  is  more  constant  in 
typhoid  fever. 

Scarlet  fever,  measles,  and  especially  pneumonia  all  bear  resemblance 
to  grippe  at  the  beginning.  I  have  seen  the  erythema  which  sometimes 
complicates  grippe  add  to  the  difficulty  in  diagnosing  between  grippe 
^  Nothnagel,  Encyclopedia  of  Pract.  Med.,  Amer.  Edit.,  Influenza,  569. 

2  Bureau  of  the  Census.     Ref.,  Med.  Rec,  1918,  CXIV,  906. 

3  Monthly  Bull.,  loc.  cit.  20. 


GRIPPE  481 

and  scarlet  fever.  The  course  of  the  case  serves  later  to  distinguish 
them.  Malaria  exhibits  usually  a  more  regular  temperature  curv^e, 
the  spleen  is  decidedly  enlarged,  and  the  malarial  organism  can  be  found 
in  the  blood. 

Gastroenteritis  at  first  resembles  exactly  the  gastroenteric  type  of 
grippe.  The  sudden  clearing  up  of  the  symptoms  will  distinguish  the 
latter  in  the  course  of  a  few  days.  The  existence  in  several  members  of  a 
family  of  fever  with  decided  enlargement  of  the  cervical  lymphatic  glands, 
an  occurrence  which  has  frequently  been  observed  in  influenza,  sometimes 
causes  the  diagnosis  of  glandular  fever  to  be  made.  Undoubtedly  such 
mistakes  are  common.  The  prevalence  of  grippe  and  the  presence  of 
undoubted  symptoms  of  it  in  combination  with  the  glandular  enlarge- 
ment, will  generally  make  the  diagnosis  evident. 

Treatment.  Prophylaxis. — The  great  contagiousness  of  the  disease 
renders  necessary  the  protection  of  those  not  affected,  particularly  infants 
and  dehcate  children.  This  is,  however,  difficult  of  accomplishment  dur- 
ing epidemics.  Certainly  the  ill  child  should  be  isolated  as  far  as  pos- 
sible. It  is  still  better  to  remove  the  other  children  from  the  house. 
Quarantine  should  continue  while  evidence  of  respiratory  catarrh  persists, 
since  living  microorganism  are  probably  still  present  in  the  secretion. 
The  value  of  prophylactic  vaccines  is  still  undetermined  in  spite  of  the 
careful  study  which  has  been  given  to  the  subject,  and  the  wide  trial  of 
vaccines  which  was  made  in  the  1918  epidemic. 

Treatment  of  the  Attack. — The  brief  course  of  the  uncomplicated 
disease  and  the  low  mortality  usually  renders  little  treatment  necessary. 
There  is  no  specific  known  and  therapy  must  be  symptomatic.  What 
has  been  said  of  vaccines  for  prophylaxis  applies  equally  well  here. 
Rest  in  bed  is  imperative.  The  diet  should  be  light,  nourishing  and 
abundant.  Fever  may  be  treated  by  ordinary  febrifuges  and  a  laxative, 
or  if  high,  by  sponging  or  a  warm  bath.  Pain  may  be  relieved  by  small 
repeated  doses  of  the  coal-tar  derivatives,  preferably  phenacetin  and  anti- 
pyrine,  given  cautiously.  (See  pp.  229,  231  for  dosage.)  Vomiting  may 
be  checked  by  free  opening  of  the  bowels  and  by  the  administration  of 
bismuth,  lime  water,  bromides  or,  possibly,  opiates.  Antiseptic  alkaline 
sprays  to  the  nasal  mucous  membrane  are  of  advanatge.  Alcoholic 
stimulants  or  strychnine  are  needed  if  there  is  much  prostration.  Harass- 
ing cough  may  require  sedative  treatment.  Cerebral  symptoms  may 
need  bromides,  coal-tar  preparations  or  opiates.  Warm  baths  combined 
with  cold  to  the  head  may  prove  useful  under  these  conditions. 

Complications  must  136  guarded  against  as  far  as  possible.  Exposure 
to  chilling  by  too  early  leaving  the  bed  or  the  room  may  precipitate  a 
relapse  or  predispose  to  pneumonia.  Keeping  the  ears  carefully  covered 
during  the  attack  may  tend  to  prevent  an  otitis.  Complications  develop- 
ing should  receive  the  treatment  appropriate  to  them. 

In  the  case  where  the  convalescence  is  slow  and  the  remaining  debility 
presistant,  tonic  treatment,  careful  and  abundant  diet,  and  often  change 
of  climate  may  be  indicated. 


31 


482  THE  DISEASES  OF  CHILDREN 

CHAPTER  XIV 

PERTUSSIS 
(Whooping-cough) 

History. — The  first  published  recognition  of  pertussis  was  by 
Baillou^  in  Paris  in  1578.  Willis^  observed  it  in  England  in  1658  and 
described  it  clearly.  After  the  middle  of  the  18th  century  the  disease 
spread  widely  and  is  now  one  of  the  commonest  of  the  acute  infectious 
disorders  over  the  whole  civilized  world. 

Etiology.  Predisposing  Causes. — Climate,  race  and  geographical 
position  exert  no  influence,  and  that  of  sex  is  immaterial,  females  ap- 
pearing slightly  more  predisposed.  The  statistics  regarding  season  are 
at  variance,  but  on  the  whole  pertussis  would  appear  more  frequent  in 
the  colder  months,  possibly  through  the  more  intimate  association  of 
children  in  schools  at  this  time.  The  statistics  of  Luttinger,^  however, 
upon  6868  cases  showed  a  greater  prevalence  during  the  spring  and 
summer.  Poor  hygienic  conditions  favor  the  dissemination  of  the  dis- 
ease, but  predispose  in  no  other  way.  The  previous  state  of  health  is  an 
etiological  factor  to  some  extent,  weakly  and  sickly  children  apparently 
contracting  pertussis  more  readily  than  others.  The  existence  of  other 
diseases  does  not  prevent  its  development,  and  it  is  certain  that  out- 
breaks of  pertussis  are  especially  liable  to  accompany  or  to  prevail  after 
epidemics  of  measles,  although  uncertain  whether  there  is  an  actual 
etiological  relationship. 

Age  exercises  a  powerful  predisposing  influence.  The  majority  of 
cases  occur  under  6  and  comparatively  few  after  10  years.  Szabo*  re- 
ports 1028  cases  (20.75  per  cent.)  in  the  1st  year  out  of  a  total  of  4951. 
"V^adimirov^  gives  the  incidence  of  the  disease  in  4623  cases  as  follows: 

Table  68. — Incidence  of  Pertussis  as  Regards  Age 

Under  6  months 5.5  per  cent. 

6-12  months .- 11.1  per  cent. 

1-  2  3'ears 18 . 1  per  cent. 

2-  3  years 14 . 2  per  cent. 

3-  4  years 11.6  per  cent. 

4-  5  years 9.1  per  cent, 

5-  6  years 7.9  per  cent. 

6-  7  years 6.1  per  cent. 

7-  8  years 4.7  per  cent. 

8-  9  years 4.1  per  cent. 

9-10  years 3.3  per  cent. 

10-1 1  years 1.7  per  cent. 

1 1-12  years 1.3  per  cent. 

12  years  and  over 1.2  per  cent. 

Baginsky*^  found  in  2651  cases  in  children  830  (31.3  per  cent.)  from 
birth  to  1  year,  1308  (49.4  per  cent.)  from  1  to  4  years,  502  (18.2  per  cent.) 
from  4  to  10  years,  and  11  (0.4  per  cent.)  from  10  to  14  years.     Finally 

1  Geneva  Edition,  1742. 

2  Path.  Cerebri,  etc..  Cap.  XII,  1667. 

3  Amer.  Jour.  Dis.  Child.,  1916,  XII,  290. 
*  Pest,  med.-chir.  Presse.  1881,  No.  33. 

5  Bolnitch,  Gaz.  Botk.,  1893,   No.  12.     Ref.  O'Dwyer  and  Norton,  20th  Century 
Practice  of  Med.,  XXIV,  217. 
^  Kinderkrankheiten,  1905,  265. 


PERTUSSIS  483 

in  an  analysis  by  Luttinger^  of  10,000  cases  the  age-incidence  was: 
Under  1  year  19.4  per  cent. ;  1  to  2  years  20.1  per  cent.;  2  to  5  j'-ears  40.1 
per  cent.;  5  to  15  years  ]7.9  per  cent.;  15  years  and  over  2.3  per  cent. 

It  is  evident  that  the  greater  immunity  of  the  1st  year  seen  in  some 
other  infectious  diseases  does  not  obtain  to  any  extent  in  pertussis. 
Even  cases  of  congenital  pertussis  have  been  reported  (Rilliet  and 
Barthez;^  Gatti;^  Cockajme*). 

The  individual  susceptibility  is  very  great  and  the  majority  of  chil- 
dren exposed  contract  the  disease.  That  it  is  comparative!}"  uncommon 
in  adults  depends  largely  on  the  fact  that  so  many  have  alread}'^  suffered 
earlier  in  life.  Some  children,  however,  possess  a  natural  immunity. 
Epidemic  influence  is  marked,  many  more  cases  occurring  in  some  years 
than  in  others.     The  disease  is  practicalh"  endemic  in  larger  cities. 

Exciting  Cause. — Pertussis  has  been  variously  described  as  a  pure 
neurosis  of  the  medulla  or  of  the  nerves  which  control  cough,  a  simple 
bronchial  catarrh,  and  a  pneumogastric  irritation  from  the  pressure  of 
enlarged  bronchial  lymphatic  glands.  Its  evident  infectiousness,  how- 
ever, indicates  that  it  is  certainly  dependent  upon  the  action  of  some 
microbe  contained  in  the  respiratory  secretions.  Very  minute  bacilli 
found  in  the  respiratory  mucus  were  reported  by  Afanasieff,^  Czaplewski 
and  Hensel,^  Arnheim,^  Koplik,^  Jochmann  and  Krause  ^  and  others.  In 
1906  Bordet  and  Gengou^°  described  a  very  small,  ovoid.  Gram-negative 
bacillus  present  in  large  numbers  in  the  sputum  in  the  early  part  of  the 
attack.  It  resembles,  but  is  quite  distinct  from,  the  influenza-bacillus. 
The  discovery  has  been  confirmed  by  many  later  investigators,  and  the 
etiological  relationship  of  the  germ  to  pertussis  is  rendered  still  more  posi- 
tive by  agglutination  and  complement-fixation  tests;  and  by  the  claims 
(Klimenko;^^  Inaba^^)  that  with  it  the  disease  could  be  transmitted  to 
apes  and  to  puppies  (Mallory,  Horner  and  Henderson). ^^  While  it  is 
very  probable  that  pertussis  is  due  to  this  germ,  further  studies  are  needed, 
since  the  agglutination  and  complement-fixation  tests  do  not  always 
respond  positively;  there  are  probably  several  different  strains  of  the 
bacillus;  the  germ  may  be  found  in  other  conditions  certainly  not  pertussis 
(Frankel)  ;^^  and  cases  of  pertussis  are  repeatedly  encountered  in  which  no 
bacterial  cause  can  be  discovered,  or  other  bacteria  are  present,  especially 
those  belonging  to  the  group  of  the  influenza-bacillus.  The  duration  of 
life  of  the  germ  outside  of  the  body  is  probably  brief.  Rooms  occupied 
by  the  patient  soon  lose  their  infectiousness. 

Nature  of  the  Disease.— The  mode  of  action  of  the  infectious  agent 
is  uncertain.     The  studies  of  Meyer  Huni^"'  and  of  von  Herff '^  indicate 

^  Loc.  cit. 

■  Sann6,  Mai.  dos  enf.,  1891,  III,  747. 

3  La  Pediatria.  1914,  XXII,  ()S7. 

*  Brit.  Journ.  Child.  Dis..  1913,  X.  534. 

*  Petersburg;  nied.  Wochonschr..  1SS7.  IV,  323. 

«  Deutsch.  mod.  Wochonsclu-.,  1S97,  XXII,  58(3. 

'  Bcrl.  klin.  Woch.,  1900,  XXX\II,  702. 

«  Brit.  Med.  .lourn.,  1S!)7,  II,  1950. 

»  Zeitschr.  f.  Ilvg;.,  1901,  XXXM,  193. 
•0  Annal.  de  I'instit.  Pastevir,  190().  XX,  731. 
"  Dent.  med.  Woch..  190S,  XXX I\',  203. 
'2  Zeit.  f.  Kinderh.,  Orig;.,  1912,  IV,  252. 
'•^  Journ.  Med.  Res.,   1913.  XXVII.  391. 
'^  Mtinch.  ined.  Woeli..  190S,  LV,  1()83. 
'*  Zeitsohr.  f.  kliii.  Med.,  1880.  I.  4(11. 
'6  Deut.  Arch.  i.  kliii.  Med.,  18S(;.  XXXIX,  302.' 


484  THE  DISEASES  OF  CHILDREN 

that  the  seat  of  irritation  is  oftenest  the  nose,  larynx  and  trachea,  but 
especially  the  inter-arytenoid  fossa  on  the  posterior  wall  of  the  larynx — 
the  so-called  "cough  region,"  It  is  probable,  however,  that  the  situa- 
tion of  the  local  irritation  upon  the  respiratory  mucous  membrane  may 
vary  to  some  extent  with  the  case.  As  a  result  of  this  local  irritation  a 
paroxysm  of  cough  is  produced  by  the  accumulated  mucus  upon  the 
sensitive  region.  In  this  way  is  set  going  a  series  of  reflex  clonic  spasms 
of  the  respiratory  muscles,  the  whoop  being  due  to  an  inspiratory  spasm 
of  the  glottis.  The  process  is  repeated  until  the  offending  mucus  is 
expelled.  From  this  point  of  view  the  disease  is  chiefly  a  local  irritation 
produced  by  an  infectious  catarrhal  process.  It  seems,  however,  an 
unavoidable  conclusion  that,  in  addition  to  the  local  irritation  which 
precipitates  the  paroxysms,  there  exists  a  general  constitutional  disorder 
which  determines  the  peculiar  character  of  these,  and  that  this  character 
may  depend  upon  a  disturbance  of  the  superior  laryngeal  nerves  and  the 
respiratory  centres  in  the  medulla,  brought  about  by  a  toxin  produced  by 
the  germs  and  circulating  in  the  blood.  This  view  is  supported  by  an- 
alogy to  other  infectious  diseases;  the  production  of  attacks  of  cough  by 
excitement  and  other  disturbances  acting  reflexly;  the  greater  frequency 
of  the  cough  at  night  indicating  lesser  resisting  power  of  the  respiratory 
centres  in  the  medulla;  the  occasional  occurrence  of  congenital  pertussis, 
which  must  necessarily  be  a  blood-disorder;  the  much  increased  excita- 
bility of  the  general  nervous  system  which  is  always  present;  the  occur- 
rence of  an  agglutinative  reaction;  etc. 

Period  of  Greatest  Infectiousness. — This  is  not  certainly  determined. 
There  is  no  question  that  the  disease  is  transmitted  early  in  the  catarrhal 
stage,  and  perhaps  most  decidedly  at  this  time.  There  is  also  no  doubt, 
on  the  other  hand,  that  it  can  be  transmitted  in  the  paroxysmal  stage  and 
even  during  the  decline. 

Mode  of  Transmission. — This  is  direct  by  the  secretion  of  the  respira- 
tory tract  and  to  a  certain  extent  by  the  breath,  the  germs  being  con- 
tained in  minute  droplets  of  mucus  expelled  by  coughing.  Conveyance 
to  any  distance  by  the  air  does  not  appear  to  occur.  Only  exceptionally 
is  the  infection  carried  by  a  third  person;  and  it  is  very  probable  that  in 
most  of  such  supposed  cases  the  disease  has  in  reality  been  communicated 
by  someone  suffering  from  an  abortive  and  unrecognized  attack.  The 
germs  are  received  through  the  respiratory  tract,  the  congenital  cases  of 
pertussis  being  the  exception. 

Pathological  Anatomy.^ — There  are  no  characteristic  lesions. 
During  life  there  is  found  an  intense  redness  and  swelling  of  the  respira- 
tory mucous  membrane,  especially  of  the  larynx  and  trachea,  and  to  a 
less  extent  of  the  nose  and  pharynx,  with  the  secretion  of  viscid  mucus. 
At  autopsy  involvement  of  the  bronchial  mucous  membrane  may  also 
be  discovered,  and  very  constantly  some  degree  of  pulmonary  emphy- 
sema. Mallory  and  Horner^  found  the  Bordet-Gengou  bacillus  between 
the  cilia  of  many  of  the  cells  of  the  mucous  membrane  of  the  trachea 
and  bronchi.  Acute  bronchiectasis,  enlargement  of  the  bronchial  and 
tracheal  glands,  and  congestion  of  the  brain,  lungs  and  other  internal 
organs  are  often  found.  Some  of  the  lesions  of  comphcating  conditions 
are  generally  present  in  fatal  cases,  among  these  being  bronchopneu- 
monia, atelectasis,  cerebral  hemorrhage,  hypertrophy  and  dilatation  of  the 
heart,  especially  the  right  ventricle,  and  hemorrhages  in  various  organs, 
especially  the  brain. 

1  Journ.  of  Med.  Res..  1912,  XXVII,  115. 


PERTUSSIS  485 

Symptoms. — The  attack  is  usually  divided  into  four  periods: 
(1)  the  incubation;  (2)  the  invasion  or  the  catarrhal  stage;  (3)  the 
paroxysmal,  spasmodic,  or  convulsive  stage;  (4)  the  stage  of  decline. 
These  are  not  very  sharply  differentiated  and  vary  greatly  in  length  in 
different  cases. 

Incubation. — Owing  to  the  insidiousness  of  the  invasion  the  exact 
duration  of  incubation  is  difficult  to  determine,  but  it  probably  varies 
from  2  to  14  days  with  an  average  of  3  to  4  daj^s.  No  sjTnptoms  are 
present. 

The  Catarrhal  Stage. — The  attack  begins  with  the  symptoms  of  a  tra- 
cheobronchitis, often  with  some  degree  of  cor3^za,  sneezing,  hoarseness 
and  pharyngeal  irritation.  Slight  elevation  of  temperature  with  malaise 
and  irritability  may  be  present  at  the  beginning  and  last  a  few  days. 
The  cough  at  first  is  in  no  way  suspicious,  but  later  becomes  hard,  dry 
and  annoying.  In  typical  cases  the  chest  reveals  few  if  any  rales,  but 
sometimes  an  attendant  bronchitis  obscures  the  symptoms  and  may  be 
the  cause  of  continued  fever.  The  cough  gradually  becomes  more  severe, 
frequent,  and  paroxysmal  in  character,  and  attacks  are  especially  prone 
to  occur  in  the  night.  Finally,  distinct  whooping  develops  and  the  par- 
oxysmal stage  may  be  said  to  have  fairly  begun.  The  condition  of  the 
blood  will  be  referred  to  later. 

The  duration  of  the  catarrhal  stage  is  extremely  variable.  Some  chil- 
dren begin  whooping  after  2  or  3  days,  others  only  after  3  or  4  weeks,  or 
not  at  all.  In  general  it  averages  about  2  weeks,  but  the  j^ounger  the 
child  the  shorter  this  period. 

The  Paroxysmal  Stage. — The  beginning  of  this  period  is  usually  dated 
from  the  commencement  of  whooping.  A  typical  paroxysm  is  very 
characteristic.  Often  it  comes  on  without  warning,  but  often,  too,  the 
child  experiences  a  shght  tickling  in  the  throat  or  beneath  the  sternum, 
an  inclination  to  cough,  or  a  sensation  of  smothering  or  of  intense 
anxiety.  If  previously  lying  down  it  sits  upright  with  an  anxious  expres- 
sion and  perhaps  grasps  the  side  of  the  crib.  If  moving  about  it  drops 
its  toys  and  runs  to  its  mother  or  nurse,  or  takes  hold  of  some  of  the  furni- 
ture of  the  room.  There  is  a  brief  moment  of  holding  the  breath,  a  deep 
inspiration  follows,  and  the  attack  begins.  This  consists  of  a  series  of 
short  explosive  coughs,  so  rapidly  repeated  that  there  is  no  time  for 
respiration  between  them.  Thes©  continue  for  a  few  moments  and  num- 
ber anywhere  from  4  or  .5  up  to  1.5  or  20.  Meanwhile  the  face  becomes 
swollen,  red,  cyanotic,  and  sometimes  quite  dark  and  the  eyes  prominent 
and  congested;  the  tongue  protrudes  with  each  expiratory  effort;  tears 
flow  from  the  eyes  and  saliva  from  the  mouth;  the  veins  of  the  neck  are 
engorged;  perspiration  breaks  out  on  the  face,  and  the  pulse  increases  in 
frequency.  Finally  the  cough  ceases  and  the  respiration  often  apparently 
also,  but  in  a  moment  a  long-dj-awn,  crowing  inspiration  is  heard  which  is 
called  the  "whoop,"  and  depends  upon  a  spasm  of  the  glottis.  Im- 
mediately after  the  whoop  a  second  attack  generally  occurs  and  alter  this 
perhaps  a  third  or  fourth,  or  more.  The  whole  paroxysm  lasts  from  a  few 
seconds  up  to  several  minutes.  In  the  latter  case  there  may  be  a  mo- 
mentary period  of  rest  between  some  of  the  attacks.  Toward  the  end 
of  the  paroxysm  very  tenacious,  ropy  mucus  is  often  driven  from  the 
mouth  b}^  the  force  of  the  cough  and  this  seems  to  bring  relief,  and  retch- 
ing or  vomiting  is  hable  to  follow. 

The  paroxysms  vary  from  G  or  8  up  to  GO  or  more  in  24  hours,  not  all 
of  them  in  severe  cases  being  equally  marked.     They  are  generally  most 


486  THE  DISEASES  OF  CHILDREN 

troublesome  at  night.  They  occur  without  discoverable  reason,  or  are 
brought  on  by  such  slight  causes  as  excitement,  crying,  swallowing, 
exercise,  sudden  change  of  air,  inhalation  of  the  air  of  close  rooms,  the  use 
of  a  tongue  depressor,  hearing  another  fchild  in  a  paroxysm,  and  the  like. 
The  presence  of  mucus  on  some  part  of  the  irritated  mucous  membrane 
is  the  commonest  immediate  cause.  Auscultation  of  the  chest  during 
the  expiratory  efforts  reveals  no  respiratory  sound  and  only  the  impulse 
of  the  cough  against  the  ear.  During  the  whoop  only  a  feeble  inspiration 
is  heard  or  none  at  all.  In  severe  cases  the  urine  and  feces  may  be  involun- 
tarily expelled  and  hemorrhage  take  place  from  the  nose  or  mouth  or 
beneath  the  conjunctiva. 

More  or  less  fatigue,  usually  of  brief  duration,  may  follow  the  par- 
oxysm. In  severe  cases  the  child  may  be  covered  with  perspiration  after 
an  attack,  confused,  and  quite  exhausted.  Between  the  paroxysms 
a  characteristic  appearance  of  the  face  is  often  seen,  consisting  of  some 
degree  of  swelling  and  cyanosis,  congestion  of  the  eyes,  and  blueness of 
the  tongue. 

The  urine  in  pertussis  may  contain  albumin  in  severe  cases.  A  slight 
blowing  apical  murmur  may  be  heard,  and  on  percussion  the  cardiac 
dullness  may  be  increased  (Koplik).^ 

Thr  hlood  as  studied  by  Frohlich-  and  others,  and  more  recently  by 
Crombie,^  Kolmer,^  McGay,^  and  others,  shows  a  remarkably  high  leuco- 
cytosis,  averaging  20,000,  and  often  reaching  higher  figures,  which 
begins  early  in  the  catarrhal  stage  and  reaches  its  maximum  at  the 
height  of  the  paroxysmal  stage.  The  increase  is  seen  in  the  lymphocytes, 
the  neutrophiles  being  relatively  diminished.  The  condition  of  the  blood 
returns  to  normal  in  2  or  3  months,  the  neutrophiles  gradually  increasing 
and  the  lymphocytes  diminishing.  The  eosinophiles  are  diminished 
(Benetz).^  In  the  severest  cases  the  leucocytosis  is  greater,  while  the 
lymphocytes  are  fewer  and  the  neutrophiles  more  numerous  than  in 
those  of  average  severity  (McGay;  Crombie). 

The  severity  of  the  paroxysmal  stage  increases  for  about  2  weeks, 
and  then  continues  unabated.  Meanwhile  the  general  nutrition  and 
strength  are  but  little  affected  in  average  cases  in  previously  healthy 
children;  the  appetite  and  digestion  are  good,  and  there  is  no  fever  unless 
complications  are  present.  In  severe  cases,  however,  the  child  may  suffer 
greatly  from  lack  of  sleep  and  loss  of  food  by  vomiting,  and  emaciation 
and  debility  may  become  extreme.  As  the  disease  advances  a  few  moist 
rales  become  audil^le  between  the  paroxysm. 

The  duration  of  the  paroxysmal  stage  is  very  variable.  It  averages 
3  to  6  weeks,  but  may  be  much  longer,  while  in  the  mildest  cases  this 
stage  may  continue  not  more  than  a  week. 

This  description  of  the  typical  spasmodic  stage  does  not  apply  to 
all  cases.  Sometimes  the  paroxysms  are^so  mild  or  so  infrequent  that 
the  child  is  little  disturbed  or  perhaps  needs  rehef  only  during  the  night, 
if  at  all.  In  some  cases  no  whooping  occurs  at  any  time  and  the  other 
symptoms  are  but  little  marked.  It  is  likely  that  these  very  mild  cases 
are  often  unrecognized  and  are  the  means  of  the  dissemination  of  the 
disease.     In  others,  especially  in  the  1st  year  of  life,  the  whooping  may  be 

1  Trans.  Amer.  Pediat.  Soc,  1893,  V,  90. 

2  Jahrb.  f.  Mnderh.,  1897,  XLIV,  53. 

3  Edinb.  Med.  Journ.,  1908,  I,  222. 

*  Amer.  Jour.  Dis.  Child.,  1911,  I,  431. 

*  Cleveland  Med.  Journ.,  19X1,  X,  571. 

«  Nederl.  Tijdschr.  v.  Geneesk.,  1916,  LX,  153. 


PERTUSSIS  487 

replaced  by  dangerous  apnea,  with  unconsciousness.  In  some  instances 
the  attack  may  be  accompanied  by  violent  repeated  sneezing,  and  excep- 
tionally this  may  entirely  replace  the  cough  (Szego).^  The  paroxysmal 
character  of  the  second  stage  may  also  be  influenced  by  complications. 
It  may,  for  instance,  disappear  completely  for  a  time  if  pneumonia 
develops. 

Stage  of  Decline. — This  stage  is  naturally  not  sharply  separated  from 
the  preceding  one.  Its  beginning  is  marked  by  a  lessening  in  the  number 
and  frequency  of  the  attacks.  This  steadily  continues,  the  cough  grow- 
ing looser  and  losing  more  and  more  its  peculiar  character,  while  the 
whooping  follows  only  some  of  the  paroxysms.  Moist  rales  are  heard  in 
greater  numbers  in  the  chest  and  the  sputum  is  more  purulent.  Finally 
whooping  ceases  entirely  and  the  disease  is  over,  although  more  or  less 
cough  may  continue  for  an  indefinite  time.  The  duration  of  this  stage 
is  even  more  variable  than  that  of  the  others.  In  general  it  may  be  said 
to  average  from  2  to  3  weeks.  It  may,  however,  be  indefinitely  prolonged 
by  the  development  of  a  slight  bronchitis,  which  may  cause  a  return  of 
the  severity  and  an  increase  in  the  number  of  paroxysms.  Consequently 
during  the  winter  season  the  paroxysmal  stage  is  liable  to  be  prolonged. 

It  not  infrequently  happens  that  the  whooping  returns  after  it  has 
ceased  entirely  for  a  short  time.  This  cannot  properly  be  called  a  con- 
tinuation of  the  disease,  but  is  rather  now  a  pure  neurosis  without  any 
infectious  element.  The  actual  termination  of  the  attack  of  pertussis 
in  average  cases  may  generally  be  placed  at  the  time  when  the  whooping 
and  the  paroxysmal  character  of  the  cough  have  entirely  disappeared 
for  a  number  of  daj^s.  The  total  duration  of  the  disease  thus  equals 
from  6  weeks  to  several  months. 

Complications  and  Sequels. — Respiratory  complications  and 
sequels  are  the  most  frequent.  A  moderate  bronchitis  is  a  symptom 
of  the  stage  of  decline.  If  it  is  unusually  severe  or  develops  early  in  the 
attack,  it  is  to  be  regarded  as  a  complication.  It  is  serious  if  involving 
the  small  tubes,  or  when  occurring  in  the  1st  year  of  life.  The  most 
common  and  one  of  the  most  dangerous  complications  is  bronchopneu- 
monia. The  younger  the  child  the  greater  the  predisposition  to  it.  It 
is  also  especially  frequent  in  feeble  or  rachitic  subjects.  It  makes  its 
appearance  oftenest  during  the  height  of  the  convulsive  stage  or  later. 
During  its  presence  the  whooping  character  of  the  cough  is  liable  to  lessen 
or  disappear.  The  proportion  of  cases  of  pertussis  attacked  by  broncho- 
pneumonia varies.  Of  1731  cases  of  pertussis  in  the  Metropolitan  Asy- 
lums Board's  Hospital  in  1912,  10.43  per  cent,  developed  broncho- 
pneumonia (RoUeston).'-^  It  has  reached  even  as  high  as  33.3  per  cent. 
(See).^  Atelectasis  is  of  common  occurrence  in  severe  cases  in  infants. 
A  moderate  degree  of  pulmonary  emphysema  is  probably  always  present, 
and  occasionally  remains  as  a  sequel.  Pneumothorax  has  boon  rei)orted, 
and  croupous  pneumonia  and  pleurisy  with  serous  or  pu  ultMit  effusion 
are  occasionally  scon. 

Of  digestive  disorders  the  most  troublesome  complication  is  vomiting, 
which  may  be  so  severe  and  frequent  after  the  paroxysms  that  great 
emaciation  and  loss  of  strength  develop  rapidly.  Loss  of  appetite, 
indigestion,  and  diarrhea  are  very  often  observed  in  infants,  especially 
in  summer,  when  ileocolitis  also  is  liable  to  occur.     Prolapse  of  the  rec- 

1  Arch.  f.  Kindcrh.,  1900,  XXIX,  180. 
^  Brit.  Jour.  Child.  Dis.,  1914,  XI,  38. 
3  Arch.  g6n.  de  m6d.,  1854,  II,  279. 


488  THE  DISEASES  OF  CHILDREN 

turn  or  hernia  may  be  produced  by  the  violence  of  the  cough,  or  ulcera- 
tion of  the  frenulum  linguae  from  the  repeated  impinging  of  the  tongue 
against  the  lower  incisor  teeth.     Stomatitis  is  common  in  severe  cases. 

Nervous  complications  and  sequels  are  frequent,  among  the  most 
important  being  general  convulsions,  which  not  rarely  end  fatally.  They 
are  oftenest  seen  in  rachitic  infants,  but  occur  also  in  the  course  of  pneu- 
monia or  as  an  indication  of  intracranial  hemorrhage.  They  are  most 
liable  to  develop  in  severe  cases,  but  it  frequently  happens  that  fatal 
convulsions  attack  without  warning  an  infant  who  has  been  apparently 
little  ill.  They  may  occur  in  any  period  of  the  disease.  Spasm  of  the 
glottis  is  another  convulsive  complication  sometimes  fatal.  Aphasia, 
blindness,  deafness  and  various  psychoses  are  occasional  sequels.  They 
are  generally  of  temporary  duration,  but  sometimes  permanent.  Coma 
or  a  soporose  condition  may  occur  as  a  result  of  intracranial  disturbance. 
Different  Jorms  of  paralysis,  temporary  or  lasting,  are  not  infrequent 
sequels.  They  have  been  studied  with  especial  care  by  Valentin^  and 
by  Hockenjos.2  In  the  majority  of  instances  the  paralysis  is  central 
in  origin  and  of  a  hemiplegic  type,  or  occasionally  monoplegic  or  para- 
plegic, and  depends  upon  cerebral  hemorrhage  following  the  violent  con- 
gestion; or,  in  cases  which  recover,  sometimes  upon  temporary  passive 
congestion  and  edema.  Myelitis  and  multiple  neuritis  are  uncommon. 
Disseminated  sclerosis  has  been  reported  as  a  sequel. 

Of  cardiovascular  complications  one  frequently  seen  is  dilatation  of  the 
heart,  especially  the  right  ventricle,  which  occurs  in  severe  cases  (Koplik).* 
Degenerative  changes  in  the  cardiac  muscle  aid  in  producing  it.  Sudden 
death  may  result.  Hemorrhages  are  of  frequent  occurrence,  dependent 
upon  the  intense  passive  congestion  which  the  violent  coughing  occasions. 
Epistaxis  is  the  most  common  form  and  may  occasionally  be  severe 
enough  to  require  treatment.  Discharge  of  blood  from  the  mouth  is 
oftenest  dependent  upon  epistaxis,  the  blood  having  sometimes  been 
swallowed  and  then  vomited.  Hematemesis,  the  result  of  gastric 
hemorrhage,  is  unusual,  as  is  hemorrhage  from  the  lungs  or  ears  or  into 
the  skin.  Sub-conjunctival  hemorrhage  is  frequent  and  sometimes 
so  extensive  that  the  entire  white  of  the  eye  is  replaced  by  a  blood-red 
color.  The  most  dangerous,  although  not  frequent,  form  of  hemorrhage 
is  that  within  the  cranium,  oftenest  meningeal  in  nature.  The  effusion 
of  blood  may  be  small  and  disappear  without  permanent  injury,  or  large 
enough  to  produce  death  in  convulsions,  or  to  leave  lasting  paralysis 
of  some  sort. 

Otitis  media  is  a  not  infrequent  complication.  Albuminuria  is  often 
seen  during  the  attack  and  nephritis  is  an  occasional  complication  or 
sequel.  Glycosuria  may  develop.  Cutaneous  emphysema  is  a  rare 
occurrence. 

Other  infectious  diseases,  may  follow,  precede  or  accompany  pertussis, 
among  them  being  varicella,  diphtheria,  typhoid  fever,  rubella,  scarlet 
fever,  grippe,  and  especially  measles.  Tuberculosis  in  some  form, 
especially  as  bronchial  or  mesenteric  adenitis  or  as  tubercular  broncho- 
pneumonia, is  a  common  and  dreaded  sequel. 

Relapse. — As  already  pointed  out,  the  cough  of  pertussis  has  a  very 
great  tendency  to  return  after  a  brief  interval  through  the  action  of  slight 
bronchitis.     In  the  strict  sense  this  is  rather  a  neurosis  than  a  true  re- 

1  Thtee  de  Paris,  1901. 

2  Jahrb.  f.  Kinderhcilk.,  1900,  LI,  426. 
2  Loc.  cit. 


PERTUSSIS  489 

lapse.  It  sometimes  happens,  too,  that  the  symptoms  of  the  disease 
reappear  after  an  interval  of  weeks  or  months.  Whether  this  is  to  be 
classified  as  a  true  relapse  is  uncertain. 

Recurrence.- — This  is  very  rare,  one  attack  almost  always  giving 
permanent  immunity.  Errors  in  diagnosis  account  for  many  supposed 
second  attacks.  Le  Gendre  writing  in  189P  could  find  but  9  recorded 
cases  of  recurrence,  including  1  observed  by  himself.  Widowitz^  in  558 
cases  of  whooping  cough  in  children  found  no  instance  of  a  second  attack. 
It  is  probable  that  this  does  not  apply  so  strictly  to  adult  life,  and  that 
the,  immunity  may  occasionally  become  exhausted  at  this  period.  I 
have  seen  a  few  instances  in  which  mothers  of  children  with  pertussis 
developed  a  modified  second  attack,  and  Widowitz  records  7  instances  of 
second  attacks  of  the  disease  in  individuals  over  30  years  of  age. 

Prognosis. — Contrary  to  the  widespread  popular  opinion  pertussis 
is  a  serious  disease.  Approximately  100,000  children  died  of  it  in  the 
United  States  during  10  years  (Johnston)^  and  65,381  died  in  England  and 
Wales  during  8  years  (Sticker).*  Many  additional  deaths  which  have 
been  assigned  to  complications  or  sequels  might  properly  be  added  to 
these  figures.  Crum^  estimated  that  1  per  cent,  of  the  total  deaths  from 
all  causes  in  24  countries  depended  upon  pertussis. 

Not  only  is  the  actual  number  of  deaths  from  pertussis  large,  but  the 
case-mortality  is  very  considerable,  varying  according  to  different 
statistics  from  3  to  15  per  cent,  or  over.  The  general  mortality  from  it  in 
Philadelphia  during  5  years  equalled  6.9  per  cent.  (Graham).^  Age  is  a 
powerful  factor  in  effecting  this,  the  danger  being  the  greater  the  younger 
the  child.  In  infants  pertussis  is  a  dangerous  affection,  the  mortality 
reaching  probably  25  per  cent.  According  to  Neurath^  the  mortality  in 
6469  cases  in  Vienna  was  divided  as  follows : 

Table  69. — Age  and  Mortality  in  Pertussis 

Age  No.  of  Cases  Mortality 

1st  year 1242  25 . 3  per  cent. 

2  to  5  years 3139  6.8  per  cent. 

6  to  10  years •  1926  3.9  per  cent. 

11  to  15  years 135  7.4  per  cent. 

After  15  years 27  0      percent. 

Luttinger^  places  97  per  cent,  of  the  deaths  as  under  5  years.  After 
the  age  of  6  years  death  is  uncommon. 

The  danger  depends  much  more  on  the  complications  and  sequels 
than  on  the  disease  itself.  Weakly  and  marantic  or  rachitic  infants  are 
especially  liable  to  succumb.  The  combination  of  scarlet  fever  or  diph- 
theria with  pertussis,  or  the  immediate  precedence  of  measles,  increases 
the  danger  decidedly.  Obstinate  vomiting  is  a  cause  of  death  through 
the  marantic  state  which  results,  and  tuberculosis  is  a  not  infrequent 
fatal  sequel.  Often  asphyxia  following  a  severe  paroxysm  is  the  immedi- 
ate cause  of  a  fatal  issue  in  infancy.  By  far  the  greatest  nuniber  of 
deaths,  however,  depend  upon  the  development  of  diarrheal  diseases, 

1  Rev.  mens,  de  mal.  de  I'onf.,  1891,  IX,  496. 

2  Wioii.  klin.  Wochensclir,  1909,  XXII,  1596. 

3  Arch,  of  Pcdiat.,  1SS5,  XII,  241. 

*  NotlmaKel'.s  Kiicvclop.  of  Pract.  Med.  Amer.  Ed.  Pertussis,  548. 
s  Aiiicr.  Journ.  Puhlio  lloalth,  1915,  V,  994. 

6  Journ.  Amer.  Med.  As.soc,  1917,  LXVH,  1272. 

">  Pfaundler  and  Schlossmann,  Handb.  d.  Kindcrkr.,  1906,  I,  2,  871. 

*  Loc.  cit. 


490  THE  DISEASES  OF  CHILDREN 

convulsions  and,  especially,  bronchopneumonia,  the  last  mentioned  being 
particularly  serious  when  complicating  whooping-cough.  Probably  over 
}^  the  fatal  cases  of  pertussis  are  due  to  pneumonia.  Convulsions  or 
pneumonia  is  especially  liable  to  develop  if  rickets  and  pertussis  are 
combined. 

Diagnosis. — The  diagnostic  symptoms  in  typical  cases  consist  in 
the  evidence  of  infection;  the  gradual  development  of  cough  which  be- 
comes more  and  more  paroxysmal  and  is  finally  followed  by  a  whoop; 
the  congestion  of  the  eyes,  vomiting,  and  cyanosis;  the  tendency  for  the 
cough  to  be  worse  during  the  night;  and  the  absence  of  fever  and  of  phys- 
ical signs  of  bronchitis  commensurate  with  the  severity  of  the  symptoms. 
This  group  of  symptoms  usually  makes  the  diagnosis  simple.  In  order 
to  hear  the  cough  himself  the  physician  can  sometimes  produce  a  parox- 
ysm by  examining  the  throat  of  the  patient  with  a  tongue  depressor  or 
by  tickling  the  nasal  mucous  membrane. 

Yet  so  many  exceptions  occur  that  the  recognition  of  pertussis  often 
becomes  difficult  or  impossible.  Early  in  the  attack  the  nature  of  the 
disease  cannot  be  recognized  with  certainty.  Except  for  the  history  of 
exposure,  it  is  only  through  the  cough  becoming  more  paroxysmal  as 
time  passes,  without  evidence  of  increasing  bronchitis,  that  the  case 
becomes  suspicious.  Vomiting  may  occur  after  severe  coughing  from 
other  causes,  and  occasional  whooping,  too,  is  not  uncommon  in  children, 
and  especially  in  infants  suffering  from  severe  bronchitis.  Yet  the  com- 
bination of  fever,  shortness  of  breath  and  numerous  rales  in  the  chest 
constitute  sufficient  reason  to  exclude  pertussis.  The  failure  of  the 
whoop  to  develop  renders  the  diagnosis  uncertain,  unless  the  other  charac- 
teristics are  well  marked  and  there  is  distinct  evidence  of  infection.  In 
mild  cases  not  only  the  whoop,  but  vomiting  and  the  violent  par- 
oxysmal nature  of  the  coughing,  is  absent  or  but  little  marked.  Yet  even 
in  such  cases  the  prolonged  course  and  its  unyielding  character  to  the 
ordinary  treatment  of  tracheobronchitis  renders  the  case  suspicious  espe- 
cially if  an  epidemic  is  prevailing;  and  the  diagnosis  is  practically  certain 
if  typical  cases  develop  in  other  members  of  the  family.  In  severe  cases  in 
infancy  the  occurrence  of  cough  without  whoop  but  followed  by  attacks 
of  apnea  is  strongly  suggestive  of  pertussis.  After  an  attack  of  measles 
the  diagnosis  may  at  first  be  especially  difficult,  since  a  persistence  of 
the  bronchitis  with  fever  may  mask  the  ordinary  character  of  the  catar- 
rhal stage  of  pertussis.  A  prolonged  terminal  stage  of  pertussis  may 
arouse  the  suspicion  of  tuberculosis  of  the  lungs  occurring  as  a  sequel. 
Continued  observation  of  the  case,  and  especially  the  absence  of  fever, 
will  settle  the  diagnosis.  Tuberculous  or  simple  inflammation  of  the 
tracheal  or  bronchial  lymphatic  glands  may  produce  a  very  paroxysmal 
cough  strongly  suggesting  pertussis.  The  long  continuance  of  the  glan- 
dular affection,  and  the  absence  of  distinct  stages,  of  vomiting,  and  of 
well-marked  whooping,  tend  to  exclude  the  latter.  An  examination  of 
the  blood  may  be  an  important  diagnostic  aid,  inasmuch  as  the  leucoey- 
tosis,  especially  of  the  lymphocytes,  is  higher  than  in  other  afebrile  affec- 
tions which  could  be  confounded  with  whooping-cough.  The  agglutina- 
tive test  may  be  of  diagnostic  value  early  in  the  spasmodic  stage 
(Povitzky  and  Worth)  ;^  but  later  the  complement-fixation  is  likely  to  be 
of  more  service.  Olmstead  and  Luttinger^  concluded  that  the  latter  is 
positive  in  40  per  cent,  of  the  cases  at  the  height  of  the  disease  or  during 
its  decline. 

1  Arch.  Int.  Med.,  1916,  XVII,  279. 

2  Arch.  Int.  Med.,  1915,  XVI,  67. 


PERTUSSIS  491 

Treatment.  Prophylaxis. — In  view  of  the  great  infectiousness  of 
pertussis  and  the  danger  especially  in  infancy  and  early  childhood, 
every  care  should  be  taken  in  the  separation  of  those  with  the  disease 
from  others.  This  should  continue  at  least  for  6  weeks  in  all,  or  longer  if 
the  whooping  persists.  Although  the  infectiousness  may  generally  be 
considered  over  when  once  the  whooping  has  stopped  for  a  short  time,  it 
is  better  that  the  isolation  should  continue  for  2  or  3  weeks  after  this  event. 
Since  the  patient  is  not  confined  to  bed,  and  cannot  properly  be  kept  in 
one  room,  the  unimmune  children  of  the  family  should,  if  possible, 
be  sent  away  from  the  house,  or,  still  better,  from  the  locality  where  pertus- 
sis is  prevailing.  This  is  especially  important  in  the  case  of  those  less 
than  2  years  old  and  in  delicate  children  of  any  age.  Fumigation  and 
disinfection  of  the  house  and  its  contents  are  not  essential,  but  are  never- 
theless a  wise  precaution.     (See  also  Vaccine  Treatment,  p.  494.) 

Treatment  of  the  Attack. — The  number  of  remedial  measures  which 
have  been  tried  is  enormous.  Some  are  useless;  others  good  in  one  case; 
others  in  another.  Many  children  require  practically  no  treatment; 
others  tax  all  the  resourcefulness  of  the  physician.  A  review  of  some  of 
the  methods  recommended  may  be  given. 

(A)  Hygienic  Treatment. — Unless  some  complication  interferes,  con- 
finement to  bed  is  not  necessary  and  the  children  should  be  kept  in  the 
fresh  air  as  much  as  possible.  This  does  not  mean,  however,  that  they 
should  be  sent  out  of  doors  regardless  of  the  state  of  the  weather.  Damp 
and  windy  weather  and  all  chilling  of  the  surface  of  the  body  are  to  be 
avoided  on  account  of  the  danger  of  producing  bronchitis  or  pneumonia. 
This  is  especially  true  in  infancy  and  early  childhood,  and  at  this  period 
of  life  during  the  winter  season  the  airing  is  best  done  in  the  room  with 
the  windows  open.  Should  any  bronchitis  exist,  young  patients  must 
be  kept  in  airy  rooms  frequently  and  carefully  ventilated,  and  exposure 
to  the  air  outside  must  be  given  cautiously  if  afall  during  the  cold  season. 
It  is  an  excellent  plan  to  have  two  rooms,  one  for  the  day  and  one  for  the 
night,  each  being  constantly  open  to  the  air  when  unoccupied.  The 
sleeping  in  a  freshly  aired  room  undoubtedly  diminishes  greatly  the  num- 
ber of  paroxysms.  Clothing  should  be  sufficiently  warm  and  food  should 
be  nutritious  and  easily  digestible,  and  administered  in  small  quantities 
and  frequently  when  vomiting  is  troublesome.  In  such  cases  it  is  a 
good  plan  to  employ  a  liquid  diet,  given  immediatel}^  after  the  attacks  of 
vomiting.  Nutrient  enemata  are  occasionally  required  in  older  subjects. 
Change  of  air,  especially  to  the  seashore,  is  often  wonderfully  efficacious, 
particularly  in  cases  at  all  prolonged. 

(B)  Local  Medication. — This  has  been  largely  emph>yed,  chiefly  on 
the  ground  that  the  disease  was  a  local  infection.  It  may  l)e  divided  into 
(a)  Insufflation  of  powders  into  the  nose  and  larynx;  (h)  AppHcation  of 
solutions  by  the  spray  or  brush  or  by  irrigation;  (c)  Inhalation  of  vola- 
tile substances  or  of  gases. 

(a)  Quinine  lias  been  mixed  with  boric  acid,  acacia,  or  bicarbonate 
of  soda  and  insufflated  in  powdered  form  into  the  larynx  or  nose  2  or  3 
times  a  day.  Uesorcin,  salicyhc  acid,  benzoin,  tannic  acid,  and  iodo- 
form are  prominent  among  the  other  numerous  drugs  which  have  l)een 
used  in  this  way.  In  my  own  experience  this  method  of  treatment  is 
inferior  to  internal  medication.  It  is  certain,  too.  that  in  the  hands  of 
physicians  not  specially  trained  in  making  hiryngeal  insufflation  the  nietii- 
cament  employed  usually  does  not  reacli  the  larynx.  W'lien  it  does,  a 
threatening  spasm  of  the  glottis  may  readily  be  protluced. 


492  THE  DISEASES  OF  CHILDREN 

(6)  A  1  per  cent,  solution  of  resorcin  applied  to  the  larynx  or  to  the 
pharynx  with  the  spray  or  the  brush  has  been  much  recommended.  A 
solution  of  cocaine,  2  per  cent,  or  stronger,  applied  by  the  brush  certainly 
reheves,  but  is  distinctly  dangerous.  Prominent  among  the  other  num- 
erous drugs  have  been  used  in  this  manner  may  be  mentioned  bromide 
of  potash,  nitrate  of  silver,  chloride  of  ammonium,  tannic  acid,  peroxide 
of  hydrogen,  and  salicylic  acid.  Irrigation  of  the  nares  has  often  been 
advocated,  among  the  remedies  employed  being  peroxide  of  hydrogen, 
boric  acid,  sulphate  of  iron  (1  grain  :  1  ounce)  (0.065  :  30)  bichloride 
of  mercury  (1:6000)  and  saKcylic  acid  (1:1000).  The  treatment  is 
unpleasant  and  offers  no  advantages  over  spraying. 

(c)  Inhalations  of  gaseous  or  volatile  substances  have  certainly  often 
been  helpful.  One  of  the  most  efficacious  is  carbolic  acid  or  creasote, 
which  may  be  vaporized  from  a  strong  solution  in  a  croup  kettle,  inhaled 
from  cotton  in  a  respirator  placed  over  the  mouth  and  nose,  or  volatilized 
on  metal  by  direct  heat  from  a  small  lamp.  The  possibility  of  absorption 
and  consequent  poisoning  must  be  borne  in  mind.  Turpentine,  benzine, 
thymol,  oil  of  cypress,  camphor,  naphthalene,  and  eucalyptus  are  some 
of  the  other  drugs  recommended  for  inhalation.  Anesthetization  with 
chloroform  or  ether  has  been  advised  in  exceptionally  severe  attacks. 
The  value  of  the  fumes  of  burning  sulphur  has  also  been  urged.  The 
room  is  fumigated  after  the  child  has  left  it  in  the  morning,  aired  after 
several  hours,  and  slept  in  at  night.  Formaldehyde  preparations  have 
also  been  highly  recommended  for  inhalation,  and  good  results  have 
been  reported  with  ozone. 

(C)  Systemic  Medication. — This  method  is,  in  my  experience,  more 
reUable  and  convenient  than  that  just  described.  What  drugs  will  be  of 
benefit  depends  partly  on  the  stage  of  the  disease  and  partly  on  the 
individual  reaction  of  the  child.  In  the  initial  stage*  such  sedative  treat- 
ment as  is  useful  in  acute  tracheobronchitis  will  often  answer,  while  in 
the  stage  of  decline  expectorants  may  be  indicated,  or  drugs  exhib- 
ited to  check  excessive  secretion.  The  age  of  the  patient  is  a  factor 
also,  general  and  cardiac  stimulation  being  especially  needed  in  infancy. 

Of  the  very  numerous  drugs  employed  only  a  few  have  proven  useful 
in  the  hands  of  many  physicians.  First  to  be  mentioned  as  one  of  the 
best  is  antipyrine.  Shortly  after  its  high  recommendation  by  Sonnen- 
berger^  I  began  its  administration  with  excellent  results. ^  Children 
tolerate  it  in  relatively  large  amount.  An  initial  dose  at  3  months  may 
be  '^i  grain  (0.016)  which  in  severe  cases  may  be  rapidly  increased  to 
%  grain  (0.049)  or  even  1  grain  (0.065)  every  3  hours.  At  2  years  2  to 
3  grains  (0.13  to  0.194)  every  3  hours  may  be  given.  It  is  practically  only 
when  fever  is  present,  due  to  compHcations,  that  antipyrine  may  exert  a 
depressing  effect,  and  in  such  conditions  it  should  not  be  used.  The 
favorable  results  in  some  cases  seem  little  short  of  miraculous.  In 
others  it  is  of  no  avail  whatever.  Tussol,  a  combination  of  antipyrine 
with  hydrocyanic  acid,  has  been  highly  praised  in  doses  of  ^'i  to  5  grains 
(0.032  to  0.324)  according  to  the  age.  Bromoform,  recommended  by 
Stepp^  is  often  very  useful.  To  a  child  of  from  3  to  6  years  it  may  be 
given  3  or  4  times  a  day  in  doses  of  from  2  to  10  minims  (0.123  to  0.616) 
on  moistened  sugar.  The  initial  dose  should  be  increased  cautiously, 
and  if  the  drug  causes  drowsiness  it  should  be  abandoned. 

1  Deutsch.  med.  Wochenschr.,  1887,  XIII,  280. 

2Therap.  Gaz.,  1888,  Feb.,  84 

3  Deutsch.  med.  Wochenschr.,  1889,  XVII,  639. 


PERTUSSIS  493 

Belladonna  is  an  old  time  favorite  often  very  effective.  A  child  of  2 
years  may  begin  with  2  minims  (0.123)  of  the  tincture  or  H500  grain 
(0.00004)  of  atropine  3  times  a  day.  The  amount  may  usually  be  rapidly 
but  carefully  increased,  since  full  doses  are  generally  required. 

Quinine  has  been  proven  of  value  in  many  cases,  but  often  deranges 
the  digestion.  The  amount  required  is  generally  large,  1  grain  (0.065) 
or  more  every  2  to  4  hours  at  2  years  of  age.  The  modern  comparatively 
tasteless  derivatives  of  quinine,  such  as  euchinin  and  aristochin,  have 
been  employed  successfully  to  replace  it.  The  bromides  are  often  serv- 
iceable in  combination  with  antipyrine  and  belladonna.  Chloral,  too, 
is  useful,  especially  in  producing  sleep  at  night.  It  must,  however,  be 
given  cautiously  to  young  children  on  account  of  its  depressing  influence. 
Opium,  or  its  derivatives,  is  often  of  great  value,  particularly  if  given  in  a 
single  full  dose  at  night,  or  sometimes  in  small  doses  during  the  day. 
Phenacetin,  acetanilid  and  other  drugs  of  this  class  are  sometimes  used  in 
place  of  antipyrine,  and  are  occasionally  effective  when  this  fails. 

Among  the  numerous  other  drugs  recommended,  for  the  value  of 
which  there  is  distinctly  trustworthy  testimony,  may  be  mentioned 
turpentine,  castanea,  drosera  or  droserin,  cannabis  Indica,  asafetida, 
fluoroform,  quebracho,  camphor,  hyoscine,  grindelia,  eulatin,  adrenalin, 
veronal,  and  thyme  or  its  derivative  pertussin.  Antitussin,  an  ointment 
containing  difluorphenyl,  although  used  locally  by  inunction  on  the 
thorax,  is  a  systemic  remedy  in  its  action.  It  seems  to  be  undoubtedly 
of  benefit  in  some  instances. 

(D)  Mechanical  and  Miscellaneous  Treatment. — Here  may  be  placed  a 
number  of  methods  of  treatment  not  already  discussed.  Prominent 
among  these  is  the  employment  of  vaccination  with  anti-smallpox  vac- 
cine, the  usefulness  of  which  Italian  physicians  have  often  maintained. 
As  the  occurrence  of  other  diseases  sometimes  modifies  the  symptoms  of 
pertussis,  vaccination  may  possibly  act  in  this  way.  I  have  personally 
never  been  convinced  of  its  value.  A  modification  proposed  by  Violi^ 
consists  in  the  subcutaneous  injection  of  serum  from  vaccinated  heifers. 
Fitting  the  child  with  an  elastic  abdominal  belt  has  been  highly  recom- 
mended by  Kilmer-  for  the  control  especially  of  the  vomiting  attending 
the  paroxysms,  and  its  good  effect  has  been  maintained  by  others.  The 
employment  of  the  constant  galvanic  current  to  the  neck  and  spine  and 
the  use  of  the  pneumatic  cabinet  have  each  had  their  advocates.  Intu- 
bation was  tried  by  O'Dwyer^  in  very  severe  cases  with  remarkable 
relief.  Nageli"*  maintained  that  the  pulhng  of  the  lower  jaw  downward 
and  forward  would  abbreviate  or  mitigate  the  paroxysm,  and  this 
statement  has  been  corroborated  by  Sobel.* 

A  few  general  remarks  may  be  made  on  the  forms  of  treatment 
described.  Beginning  any  of  them  too  early  in  the  attack  is  to  be 
avoided,  since  at  the  most  they  are  symptomatic,  and  intended  only  to 
relieve  the  severe  attacks  of  coughing.  We  cannot  expect,  as  a  rule,  to 
curtail  by  them  the  duration  of  the  disease.  Mild  cases,  in  which  the 
paroxysms  arc  few  and  the  general  health  excellent,  may  require  no 
therapy  at  all  other  than  hygienic,  or  at  most,  a  sedative,  such  as  opium 
or  antipyrine,  given  at  night  to  lessen  the  cough  and  insure  sleep.     The 

'  Gaz.  hebdoin.,  1897,  XLIV,  904. 

5  New  York  Med.  Journ.,  1903,  LXXVII,  1101. 

»  20th  Cent.  Prac.  of  Med.,  XXIV,  213. 

•*  Corresp'bl.  f.  Schwciz.  Acrzte,  1889,  XIX,  417. 

«  Arch,  of  Pediat.,  1903,  XX,  418. 


494  THE  DISEASES  OF  CHILDREN 

child  should  be  spar.ed  medication  when  there  is  no  real  demand  for  it. 
Certainly  remedies  should  not  be  given  which  disturb  the  digestion,  since 
the  general  nutrition  is  so  liable  to  suffer  in  many  instances.  Further, 
to  determine  the  value  of  any  treatment  for  the  relief  of  the  paroxysms  it 
is  necessary  that  it  be  given  at  the  height  of  the  disease.  Ilemedies 
employed  toward  the  end  of  the  paroxysmal  stage  may  appear  to  do 
good,  only  because  the  severity  is  naturally  lessening  by  this  time. 
Again,  before  assuming  that  a  remed}^  is  useless  it  should  be  given  in 
sufficiently  large  dose,  of  course  with  careful  watching.  If  it  proves  of 
no  avail  in  a  few  days,  we  should  not  abandon  our  efforts  but  try  some- 
thing else,  since  no  one  method  can  be  equally  good  in  all  cases.  Com- 
plications require  measures  appropriate  to  them. 

(E)  Vaccine  Treatment. — Various  efforts  have  been  made  to  control  the 
disease  by  sera  and  vaccines.  Sylvestri^  employed  the  blood-serum 
from  convalescent  cases  of  pertussis,  and  Leuriaux-  and  Klimenko,' 
that  obtained  from  inoculated  horses.  The  greatest  interest  centers 
around  the  employment  of  vaccines  of  the  Bordet-Gengou  bacillus. 
While  the  reports  of  many  investigators  are  most  encouraging,  and  this 
is  especially  true  of  its  use  as  a  prophylactic  measure  (Hess),^  the  experi- 
ence of  others  is  opposed,  and  it  is  much  too  early  to  draw  any  positive 
conclusions.  Luttinger^  and  Shaw,*^  for  instance,  claimed  excellent 
results,  while  Von  Sholly,  Blum  and  Smith^  could  find  no  satisfactory 
evidence  that  the  vaccine  treatment  possesses  any  value.  As  already 
pointed  out,  the  Bordet-Gengou  bacillus  is  not  found  in  all  cases  of  per- 
tussis, and  in  these  the  disease  would  appear  to  depend  in  some  instances 
upon  other  microorganisms,  and  vaccines  of  the  former  could  not  possibly 
be  of  benefit.  The  treatment,  however,  appears  to  be  harmless  and  may 
well  be  tried,  especially  in  infancy,  since  at  this  period  the  disease  is  most 
to  be  feared.  The  dosage  recommended  varies  from  25,000,000  to 
500,000,000  and  over  this,  repeated  every  day  or  every  2  or  3  days.^ 


CHAPTER  XV 

MUMPS 

(Epidemic  Parotitis) 


The  title  Epidemic  Parotitis  is  only  a  partially  satisfactory  one,  for, 
although  the  parotid  glands  are  the  usual  seat  of  the  disease,  the  other 
salivary  glands  may  be  secondarih'',  or  occasionally  primarily  or  even 
solely  involved,  or  the  disorder  may  be  represented  merely  by  an  orchitis. 
The  affection  was  well  described  by  Hippocrates.  Although  confounded 
later  with  other  disorders  it  was  again  clearly  differentiated  toward  the 
end  of  the  18th  century. 

1  Gaz.  degl.  Osp.,  1901,  No.  14.     Ref.,  Mimch.  med.  Woch.,  1901,  XLVIII,  2020. 

2  La  sem.  med.,  1902,  XXII,  233. 

3  Arch,  des  sciences  biol.  de  St.  Petersb.,  1912.  XVII,  103. 
*  Journ.  Amer.  Med.  Assoc,  1914,  LXIII,  1007. 

5  Journ.  Amer.  Med.  Assoc,  1917,  LXVIII,  1461. 

«  Pediatrics,  1917,  XXIX,  20.5. 

^  Jour.  Amer.  Med.  Assoc,  1917,  LXVIII,  1451. 

8  See  Review  by  Beifeld,  Amer.  Jour.  Dis.  Child.,  1916,  XII,  177. 


MUMPS  495 

Etiology.  Predisposing  Causes. — Age  has  a  powerful  predisposing 
influence,  attacks  being  most  frequent  at  from  5  to  15  years,  and  not  un- 
common in  young  adults.  It  is  infrequent  under  2  years.  Ringberg's^ 
statistics  based  on  58,331  cases  in  Denmark  gave: 

Table  70. — Incidence  of  Mumps 

Under  1  year  of  age 205  cases,    0 .  35  per  cent. 

1  to  5  years  of  age 4,512  cases,    7 .  74  per  cent. 

5  to  15  years  of  age 12,103  cases,  20.85  per  cent. 

Even  cases  in  the  new  born  have  been  reported  (Gautier,-  13  days; 
Demme,^  2  weeks;  White, ^  7  days),  and  it  is  even  possible  for  the  infec- 
tion to  be  acquired  during  fetal  Ufe  (Homan)  .^  The  youngest  case  coming 
under  my  observation  was  in  an  infant  of  103^^  months. 

Sex  has  been  claimed  to  be  a  factor,  males  being  oftener  attacked 
than  females,  but  its  influence  is  very  questionable.  Race  and  climate 
exert  no  influence,  and  the  disease  is  widely  spread  over  the  earth.  It  is 
most  prevalent  in  the  colder  season.  Epidemic  influence  is  very  decided.- 
Localities  may  be  unvisited  for  several  years  and  then  exhibit  a  number 
of  cases.  The  epidemic  is  seldom,  however,  widespread  and  is  usually  of 
short  duration.  It  may  be  limited  to  a  school  or  other  public  institution, 
or  to  a  small  portion  of  a  city,  and  extend  thence  only  slowly,  lasting  a  few 
weeks  or  months.  The  varying  influence  of  the  epidemic  is  very  marked, 
too,  in  the  severity,  the  infectiousness,  and  the  tendency  to  complica- 
tions. The  individual  susceptibility  is  not  great  except  where  persons  are 
closely  associated,  as  in  boarding-schools  or  in  barracks,  and  the  decided 
majority  of  those  exposed  escape.  As  a  result  the  affection  is  much 
less  frequent  than  most  of  the  other  acute  infectious  diseases. 

Exciting  Cause. — The  disease  is  clearly  an  infectious  one,  being  a  blood- 
infection  with  localization  usually  in  the  salivary  glands.  That  it  is  a 
general  infection  and  not  merely  a  local  inflammation  is  proven  hy  the 
cases  in  which  the  testicle  is  first  or  solely  involved.  The  nature  of  the 
germ  is  still  not  positively  known.  Various  studies  have  been  made  by 
Capitan  and  Charrin;*'  Ollivier;^  Bordas^  and  others,  and  different  organ 
isms  described.  Among  the  most  important  contributions  is  that  of 
Laveran  and  Catrin'-*  who  found  a  diplococcus  chiefly  in  the  blood  or  the 
parotid  secretion  in  67  out  of  92  cases.  These  observations  were  con- 
firmed by  Mecray  and  Walsh^"  and  by  Bein  and  Michaelis.^^  Pick'-  dis- 
covered the  same  organism  in  fluid  obtained  from  the  parotid  by  puncture 
but  failed  to  find  it  in  the  blood.  Teissier  and  Esmein'^  found  a  micro- 
organism in  the  blood  and  saliva,  with  which  they  obtained  a  i)ositive 
agglutinative  reaction.  Clearly,  the  germ  is  not  yet  certainly  known. 
The  experiments  which  have  apparently  succeeded  in  transmitting  the 

1  Ugcskr.  f.  Liiger  5  R.  III.  5,  189(1.     Rof.,  Jahrb.  f.  Kinderheilk,  1898,  XLVII,  313 

2  Revue  mM.  Suisse  Rom.,  1883,  III,  81. 

3  Wien  mod.  Bltitt.,  1888,  XI,  1613. 

*  Brit.  Med.  Journ.,  1902,  II,  1537. 

'  Am.  Journ.  Med.  Sciences,  1855,  XXIX,  56. 

•  Compt.  rend.  soc.  biol.,  1881,  III,  192;  358. 

^  Rev.  mens,  do  nial.    de  I'cnf.,  1885,  III,  297. 

"Compt.  rend.  soc.  h'\o\.,  1S89,  XLl,  644. 

»  Compt.  rend.  soc.  biol.,  1893,  XLV,  95,  528. 
i"  Med.  Rec,  1896,  L,  440. 
"  Verhandl.  15  Kong.  f.  inn.  Med.,  1897,  441. 
"Wien.  klin.  Rund.sch..  1902,  XVI,  309. 
'»  Compt.  rend.  soc.  biol.,  1906,  LX,  803;  853;  897. 


496  THE  DISEASES  OF  CHILDREN 

disease  to  monkeys  (Gordon)^  and  to  cats  (Wollstein)^  would  indicate 
that  the  virus  is  a  filterable  one. 

Transmission  and  Period  of  Infectiousness. — Transmission  is  almost 
invariably  direct,  close  proximity  being  required;  the  germ  probably  being 
contained  in  the  breath  or  the  saliva.  It  may  be  possible  that  it  can  occa- 
sionally be  carried  by  the  clothing  of  a  third  person,  or  by  letters  and  the 
like,  but  this  seems  certainly  uncommon.  It  is  not  transmitted  by  the 
air  to  any  distance.  The  tenacity  of  life  of  the  germ  is  probably  not  great. 
The  period  of  greatest  infectiousness  is  during  the  presence  of  symptoms, 
but  numbers  of  instances  prove  that  mumps  can  be  transmitted  some  weeks 
after  complete  recovery;  as  also  even  before  swelling  appears.  The 
mode  of  entrance  of  the  germs  into  the  system  is  usually  from  the  mouth 
through  the* duct  of  Steno  into  the  parotid  gland.  That  there  may  be 
other  routes  is  indicated  by  the  occurrence  of  primary  involvement  of 
the  testicle  or  of  other  salivary  glands  than  the  parotid. 

Pathological  Anatomy. — The  benign  character  of  the  disease 
makes  the  nature  of  the  pathological  process  a  matter  little  understood, 
'Virchow's^  opinion,  based  upon  investigations  upon  secondary  parotitis, 
was  that  the  primary  lesion  is  a  catarrhal  inflammation  of  the  ducts  with 
consequent  obstruction,  followed  by  inflammation  of  the  glandular  tissue 
and  a  secondary  periparotitis.  This  latter,  together  with  involvement  of 
the  cervical  lymph-glands,  accounts  for  the  diffuse  character  of  the  swelling 
of  the  neck  as  the  disease  advances.  Suppuration  does  not  occur  except 
through  a  secondary  infection  by  pyogenic  germs.  This  theory  was  sup- 
ported by  certain  later  investigators.  Other  views  make  the  primary 
lesion  an  inflammation  of  the  interacinous  and  periglandular  connective 
tissue,  the  epithelium  remaining  normal. 

The  swelling  is  limited  to  the  parotid  glands  in  the  majority  of  cases. 
Sometimes  the  submaxillary  salivary  glands  are  also  or  only  affected, 
and  the  sublingual  gland  is  less  often  involved.  The  testicles  are  rarely 
attacked  in  childhood. 

Symptoms.  Incubation. — The  stage  of  incubation  is  a  variable  one, 
a  general  average  being  2  to  3  weeks.  Periods  as  short  as  3  (Demme)* 
and  as  long  as  30  days  (Anthony)^  have  been  reported. 

Invasion. — Prodromal  symptoms  are  absent  or  overlooked  in  the 
majority  of  cases.  When  present  they  consist  of  irritability,  malaise, 
chilliness,  headache,  general  neuralgic  pain,  disturbed  sleep  or  somnolence, 
loss  of  appetite,  and  moderate  fever.  These  continue  from  a  few  hours 
to  2  days.  Sometimes  earache,  moderate  sore  throat,  vomiting  and 
diarrhea  are  seen.  Convulsions  are  exceptional.  Barthez  and  Sann^^ 
observed  prodromes  in  1  out  of  every  3  cases  in  their  hospital  practice. 

Stage  of  Swelling. — On  the  2d  or  3d  day  of  the  invasion,  if  prodromal 
symptoms  have  been  noted,  evidences  of  local  involvement  appear.  There 
is  a  dull,  aching  pain  in  the  region  of  the  ear  and  cheek,  usually  on  but 
one  side.  It  is  made  worse  by  pressure  and  often  by  movement  of  the 
jaws,  or  by  the  presence  in  the  mouth  of  acid  or  cold  substance^.  It 
increases  gradually  during  several  days,  keeping  pace  with  the  swelling, 
and  movement  of  the  head  may  become  painful.     Pain  in  the  ear  is  not 

1  Rep.  Local  Gov.  Board,  London,  1914.  Ref.,  Journ.  Amer.  Med.  Assoc,  1914, 
LXIII,  414. 

2  Jour.  Amer.  Med.  Asso.,  1918,  LXXI,  639. 

*  Annalen  des  Charite  Krankenhaus,  1858,  VII,  3,  1. 

*  Wien.  med.  Blatt.,  1888,  XI,  1613. 
«  La  sem.  m6d.,  1893,  XIII,  99. 

6  Mai.  des  enf.,  1891,  III,  696. 


MUMPS 


497 


PWH 

Fig.    153. — Mumps. 

Swelling  of  left  parotid  gland.      From    a  patient 

in  the  Children's  Hospital  of  Philadelphia. 


uncommon.  The  degree  of  pain  in  general  varies  greatly  with  the  indi- 
vidual. In  mild  cases  the  mouth  can  be  opened  readily  and  widely, 
chewing  offers  little  difficulty, 
and  there  is  but  little  pain 
in  the  face.  In  severe  cases 
the  teeth  can  scarcely  be 
separated,  chewing  is  im- 
possible, speaking  and  swal- 
lowing difficult,  and  there  is 
much  aching  in  the  parotid 
gland,  increased  by  the  con- 
gestion whicheating  occasions. 
A  few  hours  after  the  first 
development  of  pain,  sivelling 
begins  and  increases  rapidly. 
It  appears  first  in  the  region 
of  the  parotid  gland,  the  out- 
line of  which  can  be  more  or 
less  distinctly  felt  below,  in 
front  of,  and  behind  the  ear 
(Fig.  153).  Sometimes  only 
a  portion  of  the  gland  is 
attacked  at  first.  The  swell- 
ing spreads  in  every  direction 
to  an  extent  dependent  upon 
the  degree  of  involvement  of 
the  other  salivary  glands,  the 
cervical    lymphatic  glands,  and   the    subcutaneous   tissue.      In  well- 

marked  cases  it  reaches  from  the 

^^^^^■■■■■■^V  angle  of  the  jaw  well  up  toward 

^^^^^^^^^^^^^^^^  the   eye,  and   from  the  mastoid 

^^HpPRH^^^I^  process    to    the   anterior  portion 

m^^^  ^^^^  of  the  neck.     The  lobe  of  the  ear 

Hk  •  ^R  seems  lifted  up  and  pushed  out- 

^K  m  ward  (Fig.  154).     In  severe  cases 

W^  W  the  process  may  extend  about  the 

-^  eye,    causing  edema  of    the   lid, 

chemosis,  or  even  exophthalmos; 
or  it  may  reach  to  the  clavicle, 
or  across  the  neck  connecting  the 
two  sides.  In  some  instances  the 
whole  side  of  the  face  is  so  swollen 
that  the  outline  of  the  jaw  is 
obliterated,  and  the  patient  may 
be  almost  unrecognizable.  The 
swelling  is  hard  and  moderately 
tender  on  pressure.  This  is 
especially  so  over  the  central 
portion,  where  it  is  clHclly  parotid; 
while  in  the  periphery  the  in- 
filtrated connective  tissue  offers 
a  lesser  degree  of  resistance.  The 
skin  covering  it  is  tense  and  shining,  but  not  reddened.  After  the  maxi- 
mum  is  reached,   in  from  2  to  4  days  or  sometimes  later,  diminution 

32 


Fiu.   154. — Ml  MI'S. 
Fifth    day    of  the  disease,  showing    ever- 
sion  of  the  lobes  of  the    ears,    and    swelling 
of  the  parotid  region  on  both  sides. 


498 


THE  DISEASES  OF  CHILDREN 


in    the    size    of    the    sweUing    begins    and    progresses    with    variable 
rapidity. 

In  the  great  majority  of  cases  the  second  parotid  is  attacked  1  to  2 
days  after  the  onset  of  the  disease  in  the  first.  Sometimes  the  interval 
is  decidedly  longer,  and  the  involvement  of  the  first  parotid  may  have 
entirely  disappeared  before  that  of  the  second  begins.  The  degree  of 
swelling  in  the  two  glands  is  frequently  different.  In  some  epidemics  in- 
volvement of  both  parotids  is  much  less 
common  than  in  others. 

Quite  frequently  the  disease  attacks  the 
submaxillary  salivary  glands  as  well  as  the 
parotids.  The  incidence  of  this  occurrence 
varies  with  the  epidemic.  Fabre^  found  it  29 
times  in  58  cases,  the  swelling  being  nearly 
always  secondary  to  the  parotid  involvement; 
but  this  frequency  is  rather  uncommon. 
Nevertheless,  in  an  exceptional  epidemic 
reported  by  Spengler-  the  inflammation  was 
predominantly  submaxillary.  Quite  unusually 
the  submaxillary  glands  are  attacked  without 
involvement  of  the  parotid.  This  was  true, 
for  instance,  in  7  of  Fabre's  cases,  while  in  9 
others  the  infection  was  primary  here,  and 
secondary  in  the  parotids.  In  6  of  Wer- 
theimer's^  77  patients  the  submaxillary  was 
alone  affected.  In  cases  of  submaxillary 
involvement,  an  oval,  rather  soft  swelling  is 
found  below  the  jaw  on  one  or  both  sides. 
Involvement  of  the  sublingual  gland  is  un- 
common. It  may  exceptionally  occur  alone 
or  be  followed  by  parotitis  (Fabre).  It  pro- 
duces a  swelling  under  the  anterior  portion 
of  the  floor  of  the  mouth. 

During  the  first  3  or  4  days  of   mumps 


,«,o,-».- 

Zi 

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Jo 

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z 

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Fig. 


155. — Mumps    of    Mod- 
erate Severity. 
William  K.  F.,  aged  9  years. 

Apr.  27,  swelling  began  in  right  jever  continues,  the  degree  depending  upon 
parotid  without  pain  or  tender-  ^^e  Severity  of  the  attack  (Fig.  155) .  A  rise 
rrness°"Apr!  S'  Sh'sSs"  to  102°F.  (38.9°C\)  is  the  average,  although 
decidedly  swollen,  ear-lobes  Occasionally  104°F.  (40°C.)  is  attained,  while 
everted,  anything  cold  in  mouth  in  mild  cases  it  may  be  absent.  The  secre- 
gives  pain;  May  2,  swelling  of  ^-^^^  Qf  gahva  is  often  much  diminished, 
a"£Liri2  SpTd,;;  Ma°y  kaving  the  mouth  dry;  often  unaffected  or 
4,  right  side  normal,  some  Occasionally  increased.  Malaise  and  some 
puffiness  on  left  side  and  under  degree  of  prostration  are  evident,  the  appetite 
^hin.  poor   and  sleep   disturbe4-     Swelling  of  the 

tonsils  and  redness  of  the  mucous  membrane 
of  the  fauces  and  of  the  mouth  is  not  infrequent.  There  may  be  deaf- 
ness and  tinnitus,  vomiting,  diarrhea  or  epistaxis.  In  severe  cases 
there  may  be  headache,  delirium,  apathy,  somnolence,  and  even  ex- 
ceptionally convulsions  or  the  symptoms  of  the  typhoid  state  with 
enlargement  of  the  spleen.  Very  frequently,  however,  the  children  do 
not  feel  ill  enough  to  desire  to  stay  in  bed.     The  urine  may  exhibit  a 

1  Gaz.  med.  de  Paris.,  1887,  7s,  IV,  510. 

2  Med.  Zeitung.,  1885,  XXI,  183. 

3  Miinch.  med.  Wochenschr.,  1893,  XL,  656. 


MUMPS  499 

febrile  albuminuria  if  the  temperature  is  high.  Bradj'carciia  is  a  common 
symptom,  the  pulse  not  infrequently  equalling  40  or  50  in  the  minute 
(Teissier ;i  Roux).- 

The  blood  in  mumps,  according  to  the  investigations  of  Sacquepee,^ 
Krestnikoff,'*  F.  Pick,^  Wile,^  Felling''  and  others,  shows  slight  or  no 
absolute  leucocytosis,  or  even  a  leucopenia;  but  always  a  relative  increase 
in  the  number  of  lymphocytes  and  decrease  of  the  polymorphonuclear 
cells. 

The  duration  of  the  disease  in  average  cases  is  5  to  8  days,  but  in  severer 
attacks  it  is  sometimes  2  to  3  weeks  before  the  swelling  is  entirely  gone. 
With  the  beginning  of  the  diminution  of  the  swelling  there  is  a  rapid 
decline  of  the  constitutional  symptoms.  The  involvement  of  the  second 
parotid  some  days  after  the  appearance  of  the  disease  in  the  first  of 
course  prolongs  the  course. 

Complications  and  Sequels. — The  most  important  of  these  involve 
the  genitourinary  apparatus.  Orchitis  could  with  equal  propriety  be 
considered  one  of  the  forms  of  the  disease.  This  is  only  rarely  observed 
in  subjects  under  12  years  of  age,  although  in  adults  it  is  common,  Comby^ 
estimating  that  it  is  seen  in  1  out  of  every  3  cases  of  mumps  in  soldiers. 
Steiner^  recorded  it  in  a  child  of  9  months,  in  this  instance  being  the 
primary  affection.  Barthez  and  Sanne^"  saw  it  3  times  in  children  of 
12  years  in  230  cases  of  mumps  in  early  life,  and  Grognot^^  reports  an 
instance  in  a  boy  of  2  years.  It  develops  oftenest  in  the  2d  or  3d  week 
of  the  disease,  and  generally  only  one  testicle  is  attacked.  Sometimes 
inflammation  of  the  testicle  is  primary  and  occurs  alone,  or  may  be  sec- 
ondary to  inflammation  of  the  submaxillary  glands.  The  pathological 
changes  are  those  of  a  simple  orchitis.  The  attending  symptoms  are  in 
part  local  and  in  part  general.  The  latter  may  be  seveie.  consisting  of 
high  fever,  prostration,  feeble  pulse,  and  sometimes  vomiting,  diarrhea, 
delirium  or  unconsciousness.  Sometimes  adynamic  symptoms  with  low 
temperature  are  observed.  After  the  3d  or  4th  day  the  constitutional 
symptoms  rapidly  disappear,  the  resolution  of  the  swelling  taking  a 
somewhat  longer  time.  Recovery  is  generally  complete,  but  atrophy 
of  the  gland  has  resulted  not  infrequently.  Very  rarelj'  an  analogous 
inflammation  may  develop  in  the  ovaries,  uterus,  female  external  genitals 
or  the  breasts.  It  is  possible  that  ovarian  involvement  occurs  oftener 
than  supposed,  since  pain  and  tenderness  are  present  in  a  considerable 
number  of  cases,  as  has  been  pointed  out  by  Troitzky '-  and  ]\IacNaughton.'' 
Prostatitis  and  urethritis  are  rare  complications.  Infectious  nephritis  is 
uncommon.  J.  A.  Miller'^  collected  30  cases  from  medical  literature  in- 
cluding the  one  reported  by  himself.     It  is  oftener  a  sequel  than  a  com- 

'  Bull.  acad.  do  ni('d.,  1912,  Jan.  1(5.     lU-L  Arch.  f.  I^nderh.,  1913,  Suppl.  Bd.,  41. 

M'hesede  Paris,  1913. 

3  .\rch.  de  mod.  oxjicr.  ot  d'anat.  i)atii..  1902,  XIV,  114. 

*  Dissert.  St.  Petcrsh.,  1902.     Kef.  .\rcliiv.  f.  Kinderh.,  1905,  XLI,  139. 

*  Wien.  med.  Rundsch.,  1902,  X\I,  309. 
«  .\rch.  of  Pediat.,  190(>,  XXIII,  669. 
'Lancet,  1913,  II,  71. 

*  f  Irancher  and  C'ombv,  Traito  dos  mal.  do  I'cnf.,  1904,  I,  449. 
»  Wion.  nicd.  Bliitt.,  ISO*),  XIX,  3S7. 

'«  Mal.  dos  onf.,  1S91,  III.  701. 

"  Gaz.  nu'd.  do  Xantos,  1907.     Ref.  Arch,  de  mod.  des  onf.,  190S.  XI,  279. 
12  Rousskv  Vratch.,  1902,  I,  No.  16.     Ref.  Xothnagel,  Spec.  Pathol,  und  Thcrap. 
1904.  Parotitis,  .5.5. 

>3  Brooklvn  Mod.  Journ.,  1903,  XVI,  11.5. 
"  Med.  News,  1905,  LXXXVI,  585. 


500  THE  DISEASES  OF  CHILDREN 

plication;  is  nearly  always  of  a  hemorrhagic  character,  analogous  to  the 
nephritis  or  scarlatina;  and  usually  terminates  in  recovery. 

Swelling  of  the  lachrymal  glands  or  of  the  thyroid  or  thymus  is 
exceptionally  seen.  Leriche^  quoted  from  literature  9  cases  of 
involvement  of  the  lachrymal  glands,  and  Joly-  reports  7  instances 
in  37  cases  of  mumps.  So  great  a  frequency  is  certainly  unusual. 
Occasionally  symptoms  of  pancreatic  involvement  are  exhibited. 
Simonin^  observed  it  10  times  in  652  cases.  Swelling  of  the  cervical 
lymph-glands  is  a  common  complication,  and  occasionally  persists  as 
a  sequel.  Stomatitis  is  sometimes  seen.  Severe  nervotis  disturbtinces 
occasionally  develop  as  complications  or  sequels.  Prominent  here  is 
meningitis  which  has  been  repeatedly  reported.  Feliciano*  collected 
14  cases,  and  the  subject  has  also  been  reviewed  by  Acker ^  who  reported 
2  cases  and  abstracted  29  in  young  persons  collected  from  medical 
literature.  The  fluid  may  be  turbid  and  with  an  excess  of  cells  (Chauffard 
and  Bordin)^  or  sero-fibrinous  (Maximo witch).''  Paralysis  of  various 
forms  may  occur  as  a  sequel.  That  of  the  face  may  be  the  result  of 
pressure  by  the  inflamed  tissue  upon  the  facial  nerve.  It  may  develop, 
too,  in  other  parts  of  the  body,  depending  upon  neuritis  or,  rarely, 
meningoencephalitis.  Such  cerebral  conditions  as  aphasia,  choreiform 
Slates,  and  severe  psychoses  have  occasionally  been  reported.  Involvement 
of  the  ear  has  been  repeatedly  recorded.  Deafness  may  be  temporary  or 
lasting,  usually  unilateral,  depending  sometimes  upon  an  otitis  media, 
but  much  oftener  upon  labyrinthine  disease.  Gallavardin^  and  Boot^ 
each  collected  51  cases  of  the  latter.  The  eye  may  exhibit  conjunctivitis 
not  infrequently,  and  keratitis,  optic  neuritis,  iritis,  and  ocular  paralysis 
have  occasionally  occurred.  Woodward  ^"^  collected  23  cases  of  optic 
neuritis  and  neuroretinitis.  In  a  number  of  instances  permanent  blind- 
ness resulted.  Polyarthritis  dependent  upon  mumps  has  repeatedly  been 
described.  The  condition  has  been  studied  especially  by  Lannois  and 
Lemoine^^  and  by  Sarda^^  who  saw  this  7  times  in  268  cases.  It  appears 
analogous  to  scarlatinal  arthritis.  Laryngeal  stenosis  is  an  occasional 
and  very  dangerous  complication,  depending  upon  edema  or  upon  pres- 
sure by  the  swollen  tissues  of  the  neck. 

In  a  small  percentage  of  cases  the  parotid  gland  suppurates  as  a 
result  of  a  secondary  pyogenic  infection.  This  is,  however,  infrequent  in 
children.     Gangrene  is  a  rare  sequel  (Demme).^^ 

Mumps  may  occur  in  combination  with  other  infectious  diseases,  such 
as  varicella,  rubeola,  pertussis,  grippe  and  scarlet  fever.  Among  other 
very  exceptional  comphcations  and  sequels  recorded  may  be  mentioned 
erythema,  purpura  hemorrhagica,  endocarditis,  pericarditis,  peritonitis 
and  pneumonia. 

1  Th6se  de  Paris,  189.3. 

2  Arch,  de  med.  et  de  pharm.  milit.,  1903,  XLI,  481. 

3  Gaz.  mal.  inf.,  1903,  V,  307. 
^  These  de  Paris,  1907. 

5  Amer.  Jour.  Dis.  Child,  1913,  VI,  399. 

^  Lancet   1904  I  1297. 

■  St.  Petersb.  med.  Wochenschr.,  1880,  V,  185. 

8  Gaz.  des  hop.,  1898,  LXXI,  1329. 

9  Journ.  Amer.  Med.  Assoc,  1908,  LI,  1961. 

"Phys.  and  Surgeon,   XXXIX,   No.   5.     Ref.    Centralbl.    f.    inn.    Med.,   1908, 
XXIX,  67. 

"  Revue  de  med.,  1885,  V,  192. 

12  Montpellier  med.,  1888,  X,  509;  XI,  15. 

"  Loc.  cit. 


MUMPS  501 

Recurrence  and  Relapse.— Second  attacks  of  mumps  are  un- 
common, but  occasionally  seen.  Some  writers  state  that  recurrence 
is  not  infrequent;  but  it  is  safe  to  say  that  the  large  majority  of  pedi- 
atrists  have  never  observed  it.  Relapse  occurs  occasionallj'  in  the  sense 
of  a  reawakening  of  the  process  in  a  gland  just  recovering  or  its  develop- 
ment in  the  second  parotid  some  days  after  the  disease  is  completely 
over  in  the  first,  Barthez  and  Sannee^  observed  it  20  times  in  230  cases 
after  an  interval  of  from  10  days  to  3  weeks.  The  appearance  of  in- 
flammation in  the  second  parotid  before  the  disease  has  run  its  course 
in  the  first  cannot  properly  be  considered  a  relapse. 

Prognosis. — Mumps  is  one  of  the  mildest  and  least  dangerous  of  the 
acute  infectious  diseases;  yet  complications  may  occur  and  exceptionally 
render  the  attack  very  severe  and  even  fatal.  In  Ringberg's  58,331 
cases^  there  were  but  7  deaths.  Demme^  saw  2  fatal  in  117  cases,  ]")oth 
of  them  from  gangrene  of  the  parotid  gland.  Death  has  also  occurred 
from  a  complicating  meningitis  or  nephritis.  The  danger  of  atrophy 
of  the  testicle  or  of  permanent  deafness  is  to  be  borne  in  mind.  In 
childhood,  however,  all  severe  complications  are  very  uncommon. 

Diagnosis. — This  rests  upon  the  rapid  development,  the  char- 
acteristic situation  and  form  of  the  swelling,  and  the  course  of  the  disease. 
Acute  cervical  adenitis  is  a  frequent  source  of  error.  In  it,  however,  the 
centre  of  the  swollen  area  appears  to  be  below  the  jaw,  while  in  mumps  it 
is  just  below  the  lobe  of  the  ear.  The  course  of  adenitis  is  much  more 
prolonged  and  the  swelling  more  tender,  with  redness  of  the  skin  covering 
it.  Mumps  primary  in  the  submaxillary  gland  cannot  at  first  be  dis- 
tinguished from  lymphadenitis.  The  more  rapid  course  and  sudden 
onset  of  the  salivary  inflammation,  the  lesser  degree  of  induration, 
and  the  development  of  cases  of  parotid  disease  in  the  household  aid 
in  making  a  diagnosis.  Sometimes,  however,  the  distinction  cannot  be 
made  immediately,  especially  if  the  case  is  not  seen  at  the  beginning  of 
the  attack.  The  diagnosis  of  sublingual  involvement  should  be  made 
only  with  great  reserve,  and  after  exclusion  of  other  possible  inflam- 
mations in  the  locality.  Association  with  mumps  in  other  salivary 
glands  or  attacking  other  inmates  of  the  house  would  generally  be  neces- 
sary to  make  the  diagnosis  certain.  A  secondary  parotitis  occurring  in 
the  course  of  other  diseases,  such  as  typhoid  fever,  sepsis,  and  the  like, 
is  slower  in  development,  unilateral,  and  tends  to  suppuration.  I 
have  more  than  once  seen  diphtheria  supposed  to  be  mumps,  the  swelling 
in  the  lymphatic  glands  and  sul)Cutaneous  tissue  of  the  nock  being  referred 
by  the  observer  to  the  parotid  gland.  Only  a  careless  failure  to  examine 
the  fauces  can  account  for  the  error. 

Treatment.  Prophylaxis. — The  prevention  of  the  spread  of  the 
disease  is  difficult,  owing  to  the  possi})ility  of  transmission  both  after  the 
symptoms  have  disappeared  and  probably  during  inculiation.  Mild  and 
unrecognized  cases  also  readily  spread  it  in  schools.  (Quarantine  to  be  of 
any  service  should  continue  8  to  4  weeks  or  longer  from  the  ai)pearance  of 
symptoms.     Fumigation  of  the  room  is  a  precaution  hardly  rc<iuired. 

Treatment  of  the  Attack.  -This  is  purely  symptomatic.  The  child 
should  be  confined  to  bed  while  there  is  fever,  and  given  a  light  diet, 
especially  one  which  does  not  require  chewing.  Acid  sul)stances,  too, 
should  be  avoided,  as  they  sometimes  increase  the  pain.     A  mild  laxative 

1  Loc.  cil.,  705. 
*  Loc.  cii. 
^  Loc.  cil. 


502  THE  DISEASES  OF  CHILDREN 

may  well  be  administered  at  the  beginning  of  the  attack,  and  a  febrifuge 
should  be  ordered  if  required.  Careful  attention  should  be  paid  to 
the  mouth  to  prevent  stomatitis  or  to  relieve  pharyngitis.  Pain  may  be 
alleviated  by  hot  fomentations  or  by  rubbing  with  warm  olive  oil,  or 
the  gland  may  be  covered  with  raw  cotton  and  the  face  rested  against 
a  hot  water  bag.  A  5  per  cent,  guaiacol  ointment  has  been  recommended 
to  relieve  pain.  Severe  nervous  symptoms  with  high  fever  require 
warm  baths  and  other  sedative  and  antipyretic  treatment. 


CHAPTER  XVI 
MALARIA 


History. — The  disease  has  existed  since  early  times,  and  different 
forms  of  it  were  well  described  b}^  Hippocrates.  It  was,  however,  con- 
founded with  many  other  affections.  A  clearer  understanding  arose 
after  the  discovery  of  the  specific  action  of  cinchona. 

Etiology.  Predisposing  Causes. — Climate  is  of  the  greatest  impor- 
tance, tropical  and  sub-tropical  countries  being  especially  the  home 
of  the  disease;  where  it  prevails,  in  many  localities,  to  an  extent  and 
with  a  severity  unknown  in  cooler  regions.  It  is,  however,  very 
widely  distributed,  although  in  temperate  climates  it  has  been  steadily 
growing  less  frequent.  Formerly  common  in  the  Middle  and  North 
Atlantic  States,  it  is  now  generally  seen  but  seldom,  or  in  few  regions; 
and  in  those  parts  of  the  tropics  where  precautions  against  it  are  taken 
its  occurrence  has  been  greatly  lessened.  Season  is  also  a  factor,  more 
cases  being  observed  in  summer  and  autumn.  All  ages  are  attacked  bj^ 
it,  but  children  seem  especially  predisposed.  Even  the  new  born  not 
infrequently  exhibit  it,  and  cases  of  fetal  malaria  are  on  record  in  which 
the  parasite  has  been  found  in  the  blood  shortly  after  birth.  The 
possibility  of  the  occurrence  has  repeatedly  been  denied,  and  without 
doubt  it  is  very  exceptional;  but  cases  which  appear  to  be  beyond  ques- 
tion have  been  reported  by  Crandall,^  Pies,^  Lemaire,  Dumolard  and 
Laffont,^  Bass,^  Simms  and  Warwick^  and  others;  and  Laffont**  has  col- 
lected 47  observations,  some  of  these  belonging,  however,  to  the  older 
literature. 

It  should  be  stated  that  the  degree  of  susceptibility  of  children  is 
disputed.  In  Concetti's^  360  cases  occurring  in  the  first  7  years  of  life, 
there  were  but  9  in  the  1st  year,  and  24  in  the  2d  year.  It  is  now,  how- 
ever, generally  believed  that  it  is  much  more  frequent  at  an  early  age 
than  these  figures  would  indicate,  and  Koch's^  studies  in  Java  appear 
to  prove  that  infection  by  the  parasite  is  very  common  even  in  infancy, 
especially  in  malarial  districts.  It  is  probable  that  in  a  large  number  of 
subjects  at  this  period  of  life  the  symptoms  are  uncharacteristic  and  un- 
recognized, and  that  the  organism  may  even  be  present  without  pro- 
ducing any  clinical  manifestations;  and  that  the  children  later  possess 

1  New  York  Polyclinic,  1893,  I,  38. 

-  Monatsschr.  f.  Kinderh.,  Grig.,  1910,  IX,  51. 

^  Bull,  et  mem.  soc.  de  mcd.  des  hopitaux,  1910,  XX,  860. 

*  Arch,  of  Pediat.,  1914,  XXXI,  251. 

5  Journ.  Amer.  Med.  A.ssoc.,  1908,  LI,  916. 

6  These  de  Paris,  1910. 

"  Traite  des  mal.  de  I'enf.,  Grancher  and  Conibv,  1904,  I,  554. 
8  Deut.  med.  Woch.,  1900,  XXVI,  88. 


MALARIA  503 

a  comparative  immunity  against  the  development  of  the  disease.  Epi- 
demic influence  exists  in  a  sense,  in  that  some  years  show  very  few  cases, 
and  other  numerous  ones  in  the  same  locahty.  Tlie  affection  is  endemic 
in  some  regions;  rarely  seen  in  others. 

Exciting  Cause. — Many  later  observations  have  confirmed  the  dis- 
covery b}''  Laveran^  in  1880  that  the  cause  of  the  disease  is  a  parasite  of 
the  sporozoa  class  called  the  Plasmodium  malariee,  hematozoon  malarise, 
hjemamoeba,  and  by  other  names.  Unlike  bacteria,  these  germs  pass 
through  a  definite  life-cycle  in  which  they  exhibit  forms  seemingly  di- 
verse. In  the  process  they  destroy  the  red  blood-corpuscles,  producing 
pigment  which  appears  in  the  leucocytes  and  in  some  of  the  tissues  of 
the  body.  It  was  later  discovered  by  Golgi^  that  there  is  more  than 
one  variety  of  the  parasite,  and  that  each  produced  a  different  form 
of  the  disease. 

But  a  very  brief  description  of  the  microcrganism  can  be  given  here: 

1 .  The  Parasite  of  Tertian  Malarial  Fever  (Plasmodium  vivax) . — The 
life-cycle  of  this  variety  in  human  blood  is  about  48  hours.  The  parasite 
consists  at  first  of  a  small,  hyaline,  unpigmented  body  with  lively  ameboid 
movements,  contained  in  the  red  blood-corpuscle.  In  24  hours  it  has 
become  about  the  size  of  the  swollen,  decolorized  corpuscle,  and  exhibits 
a  large  amount  of  black,  granular  pigment.  Segmentation  now  begins, 
producing  a  radial  arrangement  of  the  body,  and  in  48  hours  from  the 
beginning  15  to  20  small  round  spores  are  set  free  at  the  time  of  the  chill, 
which  enter  other  red  blood-corpuscles  and  begin  again  the  asexual 
cycle.  Some  of  the  mature  bodies  do  not  segment  but  pass  through 
the  sexual  cycle  when  absorbed  by  the  mosquito. 

The  Parasite  of  Quartan  Malarial  Fever  (Plasmodium  malarise). — 
The  life-cycle  of  this  form  is  72  hours.  It  appears  at  first  as  a  small, 
hyaline,  unpigmented  body  with  very  little  and  very  slow  ameboid  move- 
ment. In  48  hours  it  grows  to  about  ^-^  or  %  the  size  of  the  red  blood- 
corpuscle  containing  it,  becomes  more  pigmented,  and  loses  all  movement. 
In  60  hours  it  fills  the  red  blood-cell,  which  is  not  enlarged  or  decolorized. 
Segmentation  now  begins,  producing  a  star-shaped  or  "daisy "-shaped 
body.  This  is  followea  by  sporulation  at  72  hours  at  the  time  of  the  chill, 
5  to  10  spores  being  discharged  to  enter  other  red  blood-cells.  Certain 
mature  bodies  do  not  segment,  as  in  the  case  of  the  tertian  parasite. 

3.  The  Parasite  of  Estivo-autumnal  {Tropical)  Fever  (Plasmodium 
precox). — The  life-cycle  of  this  parasite  is  probably  variable,  ranging 
from  24  to  48  hours.  It  consists  at  first  of  a  very  small  body,  hj'aline  or 
with  little  pigment,  actively  amcl)oid,  or,  when  at  rest,  having  a  ring- 
form.  It  develops  pigment  which  is  distributed  about  the  periphery  of 
the  organism.  It  is  much  smaller  than  the  preceding  forms,  and  the 
red  blood-cell  containing  it  is  much  shrunken.  The  later  stages  of 
development  take  place  in  the  internal  organs,  especially  the  spleen 
and  the  bone  marrow,  where  the  concentration  of  pigment,  segmentation, 
and  sporulation  occur.  After  the  attack  has  lastetl  about  a  week  cres- 
centic  pigmented  l)0(lies  appear  free  in  the  blood  serum.  These  are  the 
forms  of  the  parasite^  which  hiter  pass  through  the  sexual  cycle  in  the 
body  of  the  mos(iuit().  They  are  characteristic  of  estivo-autumnal 
malaria.     In  the  course  of  development  some  of  them  form  flagellar. 

Transmission. — Malaria,  although  an  infectious  disease,  is  not  con- 
tagious in  the  ordinary  sense;  i.e.  it  is  impossible  for  one  individual  to 

1  Bull,  (le  I'arad.  de  nu-d.,  18S0.  XLV,  1235. 
=  Gaz.  dfgli  osp.,  18SG,  Vll,  419. 


504  THE  DISEASES  OF  CHILDREN 

contract  it  directl}-  from  another,  except  by  experimental  inoculation 
with  the  blood  of  the  patient.  That  it  may  be  given  in  this  way  was 
first  demonstrated  by  Gerhardt^  and  since  then  repeatedly  bj^  others, 
Manson-  was  the  first  to  indicate  clearly  that  the  disease  was  communi- 
cated to  man  by  the  mosquito,  which  acted  as  host;  Ross^  showed  that 
the  parasite  developed  in  the  body  of  mosquitoes  which  had  bitten 
malarial  patients,  and  Grassi  and  Bignani'*  succeeded  in  transmitting 
the  disease  directly  from  the  insect  to  man.  Various  species  of  the  genus 
Anopheles  are  the  only  ones  harmful.  The  insects  acquire  the  parasite, 
as  far  as  known,  only  by  sucking  the  blood  of  a  patient  with  malaria. 
In  their  bodies  the  organism  then  passes  through  another,  viz.  a  sexual, 
cycle  of  development  different  from  that  seen  in  man.  The  duration 
of  life  of  the  Plasmodium  is  uncertain,  since  whereas  the  asexual,  seg- 
mented form  is  present  in  human  blood  only  during  the  attack  of  malaria, 
the  sexual,  non-segmented  form  may  persist  there  an  indefinite  time 
without  producing  symptoms.  This  accounts  for  the  occurrence  of 
relapses  after  intervals  of  months.  It  explains,  too  the  multiplication 
of  cases  at  the  season  of  the  year  when  anopheles  begin  to  be  abundant, 
since  the  insects  then  acquire  the  parasites  from  such  individuals. 

Pathological  Anatomy. — Many  of  the  changes  found  depend  upon 
the  extensive  destruction  of  the  blood  which  the  parasites  produce.  The 
spleen  is  always  more  or  less  enlarged;  very  soft,  especially  in  children; 
and  exhibits  pigment  and  broken-down  corpuscles.  The  enlargement 
in  chronic  cases  is  great.  The  liver  may  be  hypertrophied  and  contain 
pigment,  which  gives  it  a  slate-brown  color;  the  kidneys  enlarged  and 
gray-red,  with  pigmentation  of  the  glomeruli.  The  lesions  of  acute 
nephritis  are  sometimes  seen,  or  chronic  nephritis  after  repeated  attacks 
of  the  disease.  The  gastrointestinal  mucous  membrane  and  even  the 
skin  may  exhibit  pigment. 

Symptoms.  Period  of  Incubation. — The  duration  of  this  period  is 
uncertain.     Even  in  the  disease  produced  experimentally  it  varies  from 

3  to  21  days  (Mannaberg).^ 

Typical  Forms. — The  ordinary  foi'ms  of  the  disease  occur  in  adults 
and  in  later  childhood  much  oftener  than  at  earlier  periods.  Prodromal 
symptoms  are  often  present,  lasting  1  or  more  days  and  consisting  of 
malaise,  loss  of  appetite,  vertigo,  chilliness,  yawning,  and  irritabihty. 
A  distinct  paroxysm  then  develops,  marked  by  headache,  lassitude  or 
prostration,  coated  tongue,  general  pains,  and  often  vomiting.  There 
promptly  follows  an  evident  chill  of  varying  intensity  lasting  10  minutes 
to  an  hour  or  more,  with  shaking  of  the  body,  chattering  of  the  teeth, 
sensations  of  cold,  and  a  pinched  and  blue  appearance  of  the  face.  In 
this,  the  cold  stage,  although  the  surface  of  the  body  feels  cold  to  the 
touch,  the  thermometer  shows  a  decided  rise  of  axillary  or  rectal  tem- 
perature. The  pulse  is  small.  The  second,  or  hot  stage,  is  marked  by 
the  beginning  of  the  sensation  of  fever.  The  temperature  reaches  104°  to 
106°F.  (40°  to  41.1  °C.),  the  skin  is  flushed,  the  pulse  full  and  accelerated, 
and  headache  and  thirst  are  complained  of.  The  spleen  can  often  be  felt. 
The  maximum  temperature  as  shown  by  the  thermometer  is  reached 
during  or  shortly  after  the  chill.     The  duration  of  this  stage  is  from  3  or 

4  up  to  12  hours. 

1  Zeitschr.  f.  klin.  Med.,  1884,  VII,  372. 

2  Brit.  Med.  Journ.,  1894,  II,  1300. 

3  Brit.  Med.  Journ.,  1897,  II,  1786. 

^  Ref.  Mannaberg,  Nothnagel's  Encycl.  Pract.  Med.  Amer.  Edit.,  Malaria 

117. 
*  Nothnagel's  Encyelop.  Pract.  Med.,  American  Edit.,  Malaria,  103. 


MALARIA 


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Oct.  9,  Plasmodium  foun 


Fig.   156. — Malaria,  Simple  Tertian. 

Oct.  6,  fever,  thirst,  diarrhea;  Oct.  7,  spleen  large,  free  urination; 
d  in  blood;  Oct.  13,  paroxysm  anticipated  several  hours. 


^Hji|!l1JJU^'l!'M^^-^J 


FiQ.  157. — Malaria,  Double  Tertian. 
Lizzie  Q.,  aged  8  years.     Been  having  chill  every  night  followed  by  fovor.     \'omited 
once.     Examination  showed  enlarged  spleen  and  parasites  in  blood.     Attacks  controlled 
by  20  grains   (1.29G)  of  quinine  by  mouth  and  10  grains  (.048)  by  suppository  given  on 
12th.     Previous  small  doses  without  effect. 


506 


THE  DISEASES  OF  CHILDREN 


The  second  stage  of  the  paroxysms  is  graduallj'  replaced  by  the 
third,  or  sweating  stage,  in  which  all  the  uncomfortable  symptoms  of 
fever  disappear  and  the  temperature  rapidly  returns  to  normal.  The 
amount  of  sweating  is  very  variable.  Comfortable  sleep  usually  follows. 
The  total  duration  of  the  paroxj^sm  averages  G  to  12  hours.  After  the 
paroxysm  the  patient  usually  feels  entirely  well  until  the  next  one  occurs, 
the  length  of  the  interval  depending  upon  the  type  of  malaria  present. 

The  urine  in  malaria  frequently  exhibits  albumin  in  moderate  amount. 
It  may  often  be  scanty  just  before  the  chill  and  increase  during  and  after 
the  paroxysm.  The  blood  exhibits  besides  the  parasites,  a  very  decided 
and  rapidly  developing  anemia  in  cases  which  have  had  several  paroxysms. 


Fig.   158. — Malaria,  Quartan. 
Lawrence  G.,  aged  16  years.     Tertian  fever  a  year  before.     Chills  at  intervals  for  over  a 
year.     Blood  showed  typical  quartan  bodies.     Spleen  much  enlarged.     (Thayer  &  Hewelt- 
sons  "Malarial  Fevers  of  Baltimore. ") 


Leucocytosis  is  rare  in  malaria,  but  a  relative  increase  of  the  large 
mononuclear  cells  is  considered  characteristic  by  some  investigators. 
The  leucocytes  often  contain  pigment-granules. 

Instead  of  beginning  at  almost  the  same  hour  on  the  days  of  the 
attacks,  which  is  the  rule  in  malaria,  the  paroxysms  sometimes  "antici- 
pate" slightly,  occurring  from  1  to  several  hours  before  the  full  period 
has  elapsed  (Fig.  156.)  Under  treatment  with  quinine  "postponement" 
of  the  paroxysms  for  some  hours  is  sometimes  observed. 

The  description  of  the  symptoms  as  given  apphes  to  the  intermittent 
form  of  the  disease  and  as  occurring  in  older  children.  In  man}'^  instances, 
however,  especially  in  tropical  chinates  or  in  young  children  anywhere, 
malaria  assumes  an  irregular,  continuous,  or  remittent  tjq^e,  with  the 
various  stages  of  the  paroxysm  less  marked,  or  not  at  all  so. 


MALARIA 


507 


Varieties  of  the  Typical  Form. — 1.  Tertian  Malarial  fever,  the  most 
frequent  form  in  temperate  zones,  is  that  produced  by  the  tertian  parasite. 
In  Simple  Tertian  but  one  set  of  germs  is  present,  and  paroxysms 
occur  every  other  day,  usually  at  about  the  same  hour  (Fig.  156). 
Should,  however,  two  sets  of  tertian  organism  be  present,  reaching  the 
stage  of  sporulation  on  alternate  days.  Double  Tertian,  or  Quotidian 
fever  occurs  (Fig,  157),  the  patient  having  a  paroxysm  every  day. 

2.  Quartan  fever,  depending  upon  the  quartan  parasite,  exhibits  a 
paroxysm  every  4th  day;  i.e.  with  free  intervals  of  2  days  (Fig.  158). 
Should  two  sets  of  the  organism  be  present,  paroxysms  occur  on  two  con- 


FiG.  159. — Malakia,  Aestivo-autumnal.     Showing  Irregulahly  Intermittent 

Temperature. 

Emma  B.,  aged  13  years.  Illness  began  10  days  before,  pain  in  abdomen  and  side, 
cough,  enlarged  spleen,  crescentic  bodies  in  blood.  No  chills  or  distinct  paroxysms. 
Quinine  treatment  commenced  on  28th.  {Thayer  &  Heweitsoti's  "Malarial  Fevers  of 
Baltimore. ") 


secutive  days,  with  one  day  free.     If  three  sets  are  present,  quotidian 
(i.e.  triple  (luartan)  fever  is  produced. 

3.  Estii'o-autumnal  Fever,  or  Tropical  Fever. — Both  the  other  forms 
described  are  often  denominated  "Intermittent  fever, ^^  since  the  tem- 
perature is  normal  for  at  least  a  part  of  every  day.  In  the  form  due  to 
the  estivo-autumnal  parasite  the  attack  is  usually  of  a  remittent  type; 
i.e.  the  temperature,  although  lessening  at  intervals,  does  not  reach 
normal,  and  the  paroxysms,  if  present,  are  of  longer  duration  (Fig.  159). 
Jaundice  is  common  and  gastrointestinal  symptoms  may  be  marked. 
In  other  cases  the  individual  paroxysms  may  be  little  or  not  at  all  ob- 
served, and  great  irregularities  in  the  course  are  liable  to  be  exhibited, 
and  in  still  others  the  temperature  is  continuous,  with  little  variation, 
and  the  case  may  resemble  typlioid  fever  closely.     Sometimes,  although 


508 


THE  DISEASES  OF  CHILDREN 


dependent  upon  the  estivo-autumnal  parasite,  the  attack  is  distinctly 
intermittent  and  either  quotidian  or  tertian  in  character.  The  cold  stage 
is,  however,  absent  or  less  marked,  the  rise  and  fall  of  temperature  are 
usually  more  prolonged,  and  the  patient  does  not  feel  so  well  in  the 
apyretic  period  as  when  the  disease  is  due  to  the  tertian  parasite.  The 
cases  show,  also,  an  obstinate  tendency  to  relapse. 

Cases  of  estivo-autumnal  fever,  occur  in  both  temperate  and  tropical 

regions,  but  those  of  the  severer  form  are 
encountered  principally  in  tropical  and 
sub-tropical  countries,  including  the 
Southern  United  States.  They  may  pass 
into  the  pernicious  type.  The  algid  form 
belongs  here.  It  is  marked  especially  by 
an  extreme  sensation  of  coldness,  scanty 
urine,  excessive  prostration,  vomiting, 
and  sometimes  profuse  diarrhea.  The 
temperature  is,  at  most,  only  slightly 
elevated;  often  sub-normal.  Respiration 
is  accelerated,  the  pulse  weak,  and  the 
mind  clear.  Another  variety  of  pernicious 
malaria  is  the  comatose  form,  with  high 
fever  and  rapidly  developing  unconscious- 
ness and  delirium.  The  hemorrhagic  forvi, 
or  "blackwater  fever,"  is  that  variety  of 
pernicious  malaria  characterized  especially 
by  hemoglobinuria,  jaundice  and  uncon- 
trollable vomiting.  It  is  very  uncommon 
in  childhood.  It  is  to  be  noted  that 
occasionally  cases  of  the  pernicious  type 
may  be  produced  by  the  tertian  or  quartan 
parasite. 

Tertian  malarial  fever  is  by  far  the 
most  frequent  form  of  the  di  sease  in  children 
in  temperate  zones,  the  quotidian  type 
being  especially  common.  Quartan  fever 
is  rare  in  the  northern  portions  of  the 
United  States,  and  in  the  Southern  States 
is  less  frequent  than  other  forms.  The 
estivo-autumnal    fever    is    the    prevailing 

Occasionally 
there    is    a    combination    of     the    estivo- 
autumnal  type  with  the  other  varieties. 
Irregular   Forms. — It  is  particularly 


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Mamie  R.,  aged  2  years,  8 
months.  Cough  and  cold  in  head 
2  weeks  previously,  lost  appetite. 
A  week  before  seen  began  to  have 
fever  every  other  day.     Headache, 

pain    in    abdomen,    drowsy.     Ex-     form      in     tropical      regions 
amination    on    admission    to    the 
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Pennsylvania      showed      spleen 
slightly    enlarged     to     palpation. 

Nothing  else  of  note.    Malarial    in  infancy  and  early  childhood,  although  by 
organisms  found  Apr.  19.    Child    no  means  solclv  then,  that  variations  from 

removed.         Quinine        not     ,i        ^    r-    •,      ,     "  rxu      i- 

administered.  ^^®  dennite  types  01  the  disease  are  seen,  or 

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nent. The  typical  course  is  more  often  absent  than  present  at  this  time  of 
life.  The  onset  is  more  abrupt,  the  whole  paroxysm  is  often  shorter,  and 
the  division  of  the  attack  into  stages  is  frequently  absent  or  little  marked. 
In  infants  especially  the  symptoms  may  be  so  irregular  that  the  disease 
is  frequently  overlooked.  The  chill  in  early  life  is  usually  replaced  by 
mere  coldness,  pallor,  and  blueness  of  the  face  and  extremities;  or  by 
yawning  and  drowsiness,  or  not  infrequently  convulsions.     Vomiting  is 


MALARIA 


509 


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510  THE  DISEASES  OF  CHILDREN 

a  common  initial  symptom.  In  the  hot  stage  vomiting  may  continue 
and  there  is  coating  of  the  tongue  and  loss  of  appetite.  Constipation  may 
be  present,  but  diarrhea  is  very  common  and  sometimes  is  profuse.  The 
younger  the  child  the  more  liable  is  diarrhea  to  occur.  The  infant  ex- 
hibits either  drowsiness,  or  restlessness  and  crying.  The  temperature 
is  usually  higher  in  early  life  and  is  prone  to  run  a  much  more  irregular 
course,  approaching  sometimes,  even  in  tertian  fever,  a  remittent  or 
continous  type  (Figs.  160  and  161),  due,  probabl}^,  to  the  presence  of 
a  number  of  sets  of  the  tertian  parasite.  Nervous  symptoms  are  promi- 
nent. Headache  and  pain  in  the  epigastrium,  limbs,  or  splenic  or  hepatic 
region  are  very  frequent  and  delirium  is  not  uncommon.  Bronchitis  is  a 
very  common  symptom  and  not  infrequently  there  may  be  a  degree  of 
pulmonary  congestion,  especially  in  infancy,  which  suggests  pneumonia. 
The  sweating  stage  is  absent  or  little  marked  in  children  under  2  years  of 
age,  and  when  seen  is  liable  to  be  attended  by  considerable  prostration. 

Latent  Malaria. — In  some  cases  malaria  may  be  "latent,"  the  usual 
symptoms,  including  fever,  being  absent,  and  the  disease  suggested  only 
by  such  obscure  manifestations  as  a  periodically  recurring  cephalalgia 
or  cardialgia,  periodic  diarrhea,  periodic  torticollis,  or  an  obstinate  cough 
which  yields  only  to  quinine.  It  is  to  be  noted,  too,  that  the  malarial 
parasite  may  remain  dormant  in  the  system  for  months,  and  probably 
indefinitely,  without  producing  symptoms,  the  patient  having  at  times 
recurrent  attacks. 

Chronic  Malaria.  Malarial  Cachexia. — In  patients  who  have  had 
repeated  attacks  of  malaria  a  cachexia  develops,  characterized  especially 
by  large  spleen  and  great  anemia,  with  consequent  debility,  pallor,  and 
dropsy  of  the  skin  and  sometimes  of  the  serous  cavities.  There  is  usually 
little  or  no  fever,  or  slight  rises  occur  only  for  a  short  period  in  the  24 
hours.  The  general  symptoms  are  indefinite,  consisting  of  anorexia, 
coating  of  the  tongue,  malaise,  debility,  cough  and  vague  pains.  There 
is,  in  fact,  nothing  especially  suggestive,  unless  the  patient  is  a  resident  of 
a  malarial  district,  and  only  the  examination  of  the  blood  can  determine 
the  diagnosis. 

Complications  and  Sequels. — -One  of  the  most  prominent  com- 
pUcations  is  bronchitis.  As  already  pointed  out,  it  may  sometimes  be 
the  most  suggestive  evidence  of  the  disease.  Congestion  of  the  lungs 
often  occurs  and  even  exceptionally  a  fully  developed  pneumonia. 
Epistaxis  is  an  occasional  complication.  Gastrointestinal  affections  of 
moderate  severity  are  sufficiently  frequent  to  constitute  a  symptom  of  the 
disease.  Vomiting,  however,  may  become  very  obstinate  and  diarrhea 
may  at  times  take  on  a  dysenteric  or  choleraic  character.  Jaundice  is 
not  uncommon.  Herpes  is  seen  very  frequently  and  urticaria  and 
erythema  occasionally,  and  symmetrical  gangrene  has  been  reported. 
Endocarditis  and  torticollis  have  been  observed  and  neuritis  is  an  occa- 
sional sequel.  Aphasia  and  hemiplegia  or  other  paralyses  have  been 
observed.  Acute  glomerular  nephritis  occurs  not  infrequently  in  severe 
cases  and  chronic  nephritis  may  develop  in  malarial  cachexia.  Gly- 
cosuria has  been  frequently  observed  and  vesical  irritability  with  enuresis 
is  sometimes  seen.  Malaria  may  occur  in  combination  with  or  as  a 
sequel  to  other  infectious  diseases  as,  for  instance,  pertussis,  scarlet  fever, 
smallpox,  and  syphihs.  In  some  regions  it  is  frequently  combined  with 
typhoid  fever. 

Recurrence  and  Relapse. — The  tendency  to  relapse  is  one  of  the 
great  characteristics  of  malaria.     The  germs  may  lie  dormant  in  the 


MALARIA  oil 

system  for  an  indefinite  period  and  the  disease  reappear  at  any  time. 
How  often  the  new  attack  is  a  true  relapse  due  to  an  infection  already 
present,  and  how  often  a  recurrence  through  a  reinfection  from  without, 
it  is  usually  impossible  to  say,  unless  the  patient  has  removed  to  a 
locality  certainly  free  from  anopheles.  The  occurrence  of  one  attack 
usually'  seems  to  render  the  subject  particularly  liable  to  later  ones. 
On  the  other  hand,  the  studies  of  Koch^  have  confirmed  the  opinion  of 
many  physicians  in  the  tropics  that  infected  individuals  may  finally 
become  immune,  and  that  the  natives  of  some  malarial  districts  do  not 
readily  develop  the  disease  because  of  having  had  an  attack  in  infancy. 

Course  and  Prognosis. — The  duration  of  the  disease  is  uncertain. 
Unless  treated  with  quinine  it  may  continue  indefinitely  and  pass  into 
the  chronic  stage.  In  other  cases,  particularly  of  the  tertian  type,  it 
stops  of  itself  after  a  week  or  more,  although  very  prone  to  relapse  fre- 
quently. The  pernicious  cases  end  fatally  in  a  day  or  two.  Malarial 
cachexia  may  last  months  or  years  before  complete  recovery  is  obtained. 
The  prognosis  varies  with  the  locality.  In  malarial  regions,  especially 
in  the  tropics,  the  disease  reaches  the  proportions  of  a  plague,  and  is 
the  cause  of  many  deaths.  In  temperate  climates  the  prognosis  is  usually 
good  in  districts  where  the  disease  is  sporadic  or  occurs  only  exception- 
ally in  epidemic  form.  This  is  most  true  of  the  intermittent  type,  which 
tends  to  recover  spontaneously,  particularly  if  the  subject  is  removed 
from  malarial  districts  and  repeated  reinfection  prevented.  The  irregular 
forms  run  an  indefinite  course,  and  when  they  are  dependent  upon  the 
estivo-autumnal  parasite  they  are  liable  to  be  severe.  In  the  Southern 
States  of  this  country  and  in  tropical  regions  the  estivo-autumnal  form 
is  attended  b}^  a  higher  mortality  in  infancy,  and  death  may  take  place 
in  a  few  hours  during  the  first  attack.  This  applies,  however,  only  to 
the  pernicious  variety  of  the  disease.  Under  treatment  and  outside  of 
malarial  districts  the  prognosis  of  malaria  is  favorable,  and  death  rarely 
occurs  except  from  complications.  The  great  tendency  to  relapse  has 
already  Vjcen  referred  to. 

Diagnosis. — The  diagnosis  is  easy  in  typical  cases,  but  often  presents 
great  difficulties  in  the  anomalous  and  irregular  forms,  which  are  especi- 
ally lia]:)le  to  develop  in  early  childhood  and  infancy.  A  certain  tendency 
to  periodicity  may  sometimes  be  discovered  in  these  cases,  which  is  very 
suggestive,  as  is  also  enlargement  of  the  spleen;  but  the  most  satis- 
factory diagnostic  characteristics  are  the  cure  by  quinine,  and  the  .dis- 
covery of  the  parasite  in  the  blood.  This  latter  can  usually  be  accom- 
plished when  quinine  has  not  been  administered  for  any  length  of  time, 
but  considerable  practice  and  experience  are  required.  Consequently 
the  failure  to  find  the  germs  is  no  proof  that  the  disease  is  not  malaria. 
A  single  negative  result  of  examination  should  not  suffice,  inasnmch  as  the 
organisms  may  at  the  time  be  absent  from  the  peripheral  circulation. 
The  study  is  best  made  a  few  hours  before  the  paroxysm  is  expected. 
At  its  height  they  may  not  be  discoverable.  On  the  otlier  hand,  a  fever 
of  intermittent  tyj)e  which  is  not  cured  l)y  (juinine  is  almost  certainly  not 
malaria,  and  even  the  more  irregular  and  remittent  types  will  generally 
respond  to  this  therapeutic  test,  if  sufficiently  large  doses  are  admin- 
istered. It  must  be  remembered,  however,  that  the  cure,  although 
usually  prompt,  is  not  invarial)ly  so. 

There  are  a  number  of  disorders  which  sinuilate  malaria  closely, 
prominent  among  them  being  suppurative  conditions,  such  as  empyema, 

1  Loc.  cit.,  88. 


512  THE  DISEASES  OF  CHILDREN 

pyelitis,  and  septic  processes  of  an}^  sort.  These  may  exhibit  an  inter- 
mittent fever  with  chills  and  sweats.  Careful  local  examination  may 
be  required  to  show  their  true  nature.  The  failure  of  quinine  to  relieve 
them  permanently,  and  the  presence  of  leucocytosis,  show  that  they 
are  not  malaria  even  without  an  examination  of  the  blood  for  the  para- 
sites being  made.  Malarial  fever  may  also  be  closely  simulated  at  times 
by  tuherculosis  and  by  typhoid  fever.  The  latter,  especially,  may  be  very 
like  the  remittent  form  due  to  the  estivo-autumnal  parasite,  and  some- 
times, too,  strongly  suggests  the  intermittent  type  of  malaria.  (See 
Typhoid  Fever,  p.  399,  Fig.  99. 

Rickets,  syphilis  and  forms  of  splenomegaly  may  exhibit  both  anemia 
and  enlargement  of  the  spleen,  but  have  nothing  else  to  suggest  the 
malaria  cachexia. 

It  was  a  habit,  very  common  in  former  years  of  attributing  to  malaria 
numerous  obscure  conditions  for  which  no  satisfactory  explanation 
could  be  found.  This  has  been  the  cause  of  many  a  fatal  error  in  diag- 
nosis. No  doubtful  case  should  be  called  malaria  unless  an  examination 
of  the  blood  or  successful  treatment  with  quinine  shows  that  it  really 
belongs  in  this  category. 

Treatment.  Prophylaxis. — This  consists  in  the  destruction  of  the 
anopheles,  the  protection  from  the  bites  of  the  insects,  and  the  prevention 
of  relapse  in  those  who  have  had  the  disease.  The  first  of  these  has 
been  successfully  undertaken  on  a  large  scale  by  governments  in  some 
regions.  All  accumulations  of  water  or  other  breeding  places  should  be 
spra3^ed  with  kerosene.  The  avoidance  of  relapse  is  to  be  accomplished 
by  the  frequent  administration  of  small  doses  of  quinine,  especially  at  the 
time  of  the  year  when  malaria  is  most  liable  to  occur.  Individuals  who 
are  obliged  to  visit  a  malarial  region  should  take  quinine  in  small  doses 
constantly.  Mosquitoes  should  be  kept  as  far  as  possible  from  biting 
by  the  use  of  mosquito-nettings  at  night;  by  seeing  that  the  children  are 
in  the  house  before  sunset,  since  the  anopheles  do  their  biting  at  night; 
and  by  applications  to  the  skin  of  an  ointment  containing  pennyroyal, 
menthol,  tar,  citronella  or  other  substance  disagreeable  to  the  insects. 

Treatment  of  the  Attack. — Quinine  is  a  specific,  and  the  only  one, 
although  good  results  have  been  reported  from  arsenic  in  large  doses. 
To  subjects  old  enough  it  can  best  be  given  in  capsules;  for  those  younger 
it  must  be  in  solution.  Either  the  sulphate  (74.31  per  cent,  quinine), 
the  bisulphate  (59.12  per  cent.)  the  hydrochloride  (81.71  per  cent.)  or  the 
dihydrochloride  (81.61  per  cent.)  may  be  employed.  For  solutions  the 
last  is  the  best,  as  it  is  very  soluble  and  is  fairly  rich  in  the  quinine  base. 
The  sulphate  is  comparatively  insoluble.  The  taste  of  these  salts  may  be 
disguised  to  a  certain  extent  by  the  admixture  of  syrup  of  yerba  santa, 
syrup  of  licorice,  syrup  of  chocolate,  or  other  pleasant  menstruum.  The 
tannate  (30  to  35  per  cent,  quinine)  is  much  less  effective,  but  in  the  form 
of  "quinine  chocolates,"  has  very  little  unpleasant  taste  and  is  often  taken 
readily  by  children.  Euchinin  (84  per  cent,  quinine)  and  aristochin 
(96  per  cent.)  are  two  comparatively  tasteless  quinine  derivatives  which 
may  be  used  instead  of  those  mentioned. 

Quinine  should  be  given,  when  possible,  in  a  single  large  dose  2  or  3 
hours  before  the  time  of  sporulation  of  the  parasites,  which  coincides 
with  the  occurrence  of  the  paroxysm,  since  at  this  time  the  germs  are 
outside  of  the  red  blood-cells  and  are  more  easily  killed,  A  great  objec- 
tion to  this  method  is  the  tendency  to  cause  vomiting.  When  this  occurs 
it  is  better  to  administer  the  drug  in  smaller  doses  every  2  or  3  hours 


TETANUS  513 

beginning  3  or  4  hours  after  the  paroxysm  is  over  and  giving,  if  possible, 
a  slightly  larger  amount  shortly  before  the  time  of  the  expected  recurrence. 

In  the  irregular  or  remittent  forms,  especiallj^  in  serious  cases,  the 
patient  should  receive  a  large  dose  as  quicklj^  as  possible,  and  then  be 
kept  fully  under  the  influence  of  the  drug  by  smaller  doses  repeated  at 
regular  intervals.  A  somewhat  larger  amount  is  generally  required  in 
such  cases,  particularlj^  if  the  organism  is  of  the  estivo-autumnal  t3"pe. 
Sometimes  quinine  is  borne  better  immediately  after  food,  sometimes 
on  an  empty  stomach.  When  vomiting  cannot  be  overcome,  and  in  all 
pernicious  cases,  the  remedy  must  be  given  by  the  bowel,  either  by  enema 
or  suppositor}^,  or  hypodermically.  For  hypodermic  use  the  dihydro- 
chloride  of  quinine,  or  the  hydrochloride  of  quinine  and  urea,  may  be 
employed.  The  hypodermic  employment  of  quinine  is,  however,  liable 
to  be  ver}'  irritating,  and  may  be  followed  by  abscess.  It  is  to  be  selected 
only  when  other  methods  fail,  and  the  drug  should  be  given  in  a  few  large 
doses  rather  than  in  repeated  smaller  ones.  After  the  attack  of  malaria 
has  been  controlled  quinine  should  be  continued  in  somewhat  smaller 
doses  for  2  or  3  weeks,  or  relapse  will  be  very  liable  to  occur. 

Dose. — Quinine  is  borne  by  children  in  relatively  large  doses,  and, 
except  for  the  tendency  to  produce  vomiting,  appears  to  be  a  safe  remedy. 
Taking  the  sulphate  as  the  type,  and  selecting  that  one  of  the  salts  to  be 
used  with  due  regard  to  its  comparative  basic  strength,  an  infant  of  1 
year,  with  a  mild  attack  of  malaria,  should  receive  6  to  8  grains  (0.39  to 
0.52)  in  the  course  of  24  hours,  and  sometimes  much  larger  amounts  are 
needed.  In  later  childhood  the  dose  may  be  as  large  as  for  adults. 
The  dose  for  hypodermic  use  for  24  hours*  should  be  about  the  same  as  for 
administration  by  the  mouth.  For  rectal  employment  it  should  be  2 
or  3  times  as  large,  since  absorption  is  not  perfect. 

Treatment  of  the  Paroxysm. — Little  is  needed  as  a  rule,  and  that  is 
purely  symptomatic.  Warm  covers  and  dry  heat  may  be  employed  in 
the  cold  stage,  and  sponging,  if  necessary,  in  the  hot  stage. 

Treatment  of  Chronic  Malaria. — Not  only  is  quinine  needed  here,  but 
often  such  tonics  as  iron,  arsenic,  and  the  like,  to  overcome  the  anemia. 
Removal  from  a  malarial  region  is  all-important. 


CHAPTER  XVII 
TETANUS 
(Lock  Jaw) 


History. — The  disease  was  known  to  the  ancients  and  was  described 
by  Hippocrates.  It  occasionally  attacks  older  cliilth'on,  the  cause  and 
symptoms  being  the  same  as  in  th(»  case  of  athilts;  while  in  the  new 
born  it  is  sufficiently  common  and  important  to  receive  in  many  text- 
books a  separate  (lesciiption  under  the  title  of  Tetanus  Neonatorum. 

Etiology.  Predisposing  Causes. — One  of  the  most  important  is  that 
of  age,  the  great  majority  of  cases  in  infancy  occurring  in  the  new  born. 
The  influence  of  age  is,  however,  greatly  modified  by  locality.  In  some 
countries  tetanus  neonatorum  has  at  times  been  endemic,  and  the  cause 
of  many  deaths.  These  regions  are  often  widely  separated  and  of  en- 
tirely different  climatic  conditions.  Thus,  it  has  in  certain  periods  been 
very  frequent  in  the  Hebrides,  in  parts  of  the  West  Indies  and  of  the  South- 
as 


514  THE  DISEASES  OF  CHILDREN 

ern  United  States,  and  in  a  portion  of  Long  Island.  Of  23,398  infants 
dying  in  Roumania  in  the  1st  month  of  hfe  according  to  Miron,^  10,257 
were  cases  of  tetanus.  In  general  it  is  most  frequent  in  hot  climates.  The 
disposition  of  the  disease  depends,  however,  not  so  much  on  climatic  in- 
fluences as  upon  the  absence  of  cleanliness.  Under  proper  hygienic 
conditions  it  is  rare.  The  fact  that  the  Negro  infants  in  some  regions  of 
the  Southern  States  are  especially  liable  to  it  is  not  a  proof  of  an}'-  special 
predisposing  influence  of  race,  but  rather  of  the  greater  carelessness 
regarding  hygiene  common  in  these  localities  among  the  Negroes. 

The  presence  of  a  loound,  although  minute  and  perhaps  undiscovered, 
is  apparently  necessary  to  the  development  of  the  disease.  From  this 
standpoint  all  cases  of  tetanus  must  be  considered  as  traumatic.  Punc- 
tured, lacerated  and  contused  wounds,  especially  of  the  hands  and  face, 
are  those  particularly  dangerous;  clean,  incised  wounds  much  less  so. 
Consequently,  cases  frequently  develop  after  Fourth  of  July  accidents, 
or  those  associated  with  similar  celebrations.  I  have  seen  it,  for  instance, 
follow  a  punctured  wound  by  a  nail  in  the  ruins  of  a  stable,  this  illustrat- 
ing the  connection  of  the  disease  with  the  horse.  It  is  very  probable 
that  abraded  surfaces  of  the  mucous  membrane  of  the  intestine  offer  a 
portal  of  entry  in  some  instances.  The  wound  of  ritual  circumcision 
or  that  of  vaccination,  if  imperfectly  cared  for,  may  readily  give  rise  to  the 
disease.  (See  Vaccination,  p.  382.)  Much  the  most  frequent  portal  of 
entry  in  the  new  born  is  the  umbilical  wound. 

Exciting  Cause.— The  direct  cause  has  been  proven  to  be  the  bacillus 
tetani,  discovered  by  Nicolaier  in  1884^  and  isolated  by  Kitasato  in  1889.^ 
This  is  found  in  garden  soil  and  in  the  dust  of  the  streets  in  nearly  all 
countries,  although  particularly  abundant  in  some  localities.  Derived 
from  this  source  it  is  found,  too,  in  the  intestinal  canal  of  some  herbivora. 
It  is  chiefly  on  account  of  the  occurrence  of  the  disease  in  cattle  that  the 
occasional  danger  from  vaccine  virus  arises  when  proper  precautions  have 
not  been  taken  in  its  production.     (See  Vaccination.) 

The  bacilli  inhabit  the  superficial  portion  of  the  wound  of  the  patient, 
where  an  exceedingly  virulent  poison,  the  tetanus-toxin,  is  produced  and 
whence  very  rapid  absorption  of  this  takes  place.  The  poison  exerts 
a  special  action  on  the  motor  cells  in  tlie  medulla  and  on  the  anterior 
horns  of  the  spinal  cord.  Nearly  all  investigators  agree  that  the  germs  do 
not  enter  the  blood  or  the  organs.  The  disease  is  readily  inoculated  into 
animals.  The  spores  of  the  bacilli  are  very  tenacious  of  life,  are  unin- 
jured by  exposure  to  air  or  light,  and  offer  considerable  resistance  to  the 
temperature  of  boiUng  water.  The  action  of  disinfectant  solutions  also 
must  be  prolonged  to  accomplish  their  destruction. 

Pathological  Anatomy. — There  are  no  characteristic  post-mortem 
lesions.  Congestion  of  the  brain  and  spinal  cord  and  of  their  membranes 
occurs  frequently,  but  is  probably  the  result  of  the  convulsive  condition 
rather  than  of  the  poison.  The  lungs  are  usually  congested  likewise. 
There  is  nothing  pecuHar  about  the  condition  of  the  wound. 

Symptoms. — These  vary  slightly  according  as  the  disease  affects 
the  new  born  or  older  children. 

Tetanus  Neonatorum. — The  incubation  varies  from  a  few  hours  to  10 
or  12  days  or,  exceptionally,  longer.     In  the  majority  of  cases  symptoms 

1  II  Cong.  d.  Ruman,  Gessellsch.  f.  d.  Fortsch.  u.  Verbreit.  d.  Wissensch.,  1903, 
Sept.  22.     Ref.  Schmidt's  Jahrbucher,  1904,  B.  CCLXXXI,  206. 

2  Deutsch.  med.  Wochenschr.,  1884,  X,  842. 

3  Zeitschr.  f.  Hyg.,  1889,  VII,  225. 


TETANUS  515 

appear  toward  the  end  of  the  1st  week  of  hfe.  The  onset  is  marked  by 
restlessness,  crying,  sleeplessness  and  difficulty  in  nursing,  the  infant 
grasping  the  nipple  and  pressing  it  between  the  jaws  and  then  dropping 
it  with  a  cry  of  pain.  On  examination  the  masseters  will  be  found 
contracted  and  hard  and  the.  jaws  can  be  forced  open  only  with  difficulty 
{trismus).  The  eyes  are  closed,  the  forehead  wrinkled  and  the  lips 
pouting.  In  a  few  hours  the  stiffness  extends  to  the  muscles  of  the  trunk 
and  limbs,  at  times  attended  by  arching  of  the  body.  To  these  symp- 
toms are  next  added  violent  increase  of  the  tonic  contraction;  this  coming 
on  in  paroxysms  which  last  a  few  moments,  and  which  are  repeated  in 
severe  cases  perhaps  every  few  minutes,  but  in  milder  cases  at  much  longer 
intervals.  They  are  brought  on  by  such  slight  causes  as  movement  of  the 
body,  a  draught  of  air,  and  the  like,  or  occur  without  an}'  discoverable 
reason  whatever.  During  well-developed  paroxysms  the  surface  of  the 
body,  especially  the  face,  becomes  red,  cyanotic  and  swollen;  the  eyes 
injected;  and  the  labial  commissure  pulled  downward  and  outward,  pro- 
ducing the  risus  sardonicus.  (See  Fig.  113,  under  Cerebrospinal 
Fever,  p.  421.)  The  jaws  are  closed  and  foam  comes  from  the  lips; 
the  head  is  retracted;  the  spine  often  much  arched;  the  arms  and 
thighs  extended;  the  forearms  and  legs  extended  or  slightly  flexed;  the 
thumbs  bent  into  the  palms;  the  fingers  clinched;  the  toes  flexed;  and  the 
muscles  of  the  chest  and  abdomen  hard.  The  whole  body  is  as  rigid  as  a 
rod  of  iron.  Sometimes  the  infant  is  supported  only  on  its  heels  and  the 
back  of  its  head.  The  respiration  is  irregular,  superficial  and  difficult; 
swallowing  impossible;  the  pulse  rapid  and  weak,  and  the  cry  feeble. 
Jaundice  is  not  uncommon.  Slight  clonic  spasmodic  movements  some- 
times accompany  the  attack. 

The  persistence  of  tonic  contraction,  especially  of  the  trismus,  appears 
to  vary  greatly  with  the  case.  In  the  severest  it  is  practically  unbroken 
almost  from  the  beginning;  in  the  milder  ones  complete  relaxation  occurs 
for  quite  long  intervals.  The  temperature  of  tetanus  is  variable  and 
often  irregular;  moderate  fever  or  even  normal  temperature  being  the 
rule  in  the  milder  cases;  higher  fever  and  occasionally  very  high  final 
temperature  in  the  severer  ones.  Sometimes  the  low  temperature  of 
collapse  develops. 

Tetanus  in  Older  Infants  and  in  Childhood. — Thesymptoms  differ  in  no 
way  from  those  seen  in  adults.  After  a  very  variable  incubation  period,  usu- 
ally not  over  10  days  from  the  reception  of  a  wound,  symptoms  appear,  the 
patient  complaining  of  chilliness,  headache,  fever,  stiff"ness  in  the  neck,  and 
especially  of  difficulty  in  masticating  and  in  opening  the  mouth.  (Jradual 
increase  of  stiffness  in  the  muscles  of  the  jaws  develops,  making  it  im- 
possible for  the  patient  to  separate  them;  and  the  risus  saidonicus 
appears.  The  stiffness  then  extends  to  the  muscles  of  the  body  in  gen- 
eral, especially  those  of  the  back.  Distinct  paroxysms  now  occur, 
similar  to  those  described  under  tetanus  neonatorum,  the  body  being 
bathed  in  perspiration;  the  pain  verj'  intense,  and  the  body  often  in  the 
position  of  opisthotonos,  but  sometimes  in  a  straight  position  (orthotonos) 
or  drawn  to  one  side;  (plouiothotonos);  or  douliled  forward  by  the  con- 
traction of  the  alxlominal  muscles  (emprosthotonos).  There  may  l)e 
partial  relaxation  l)etween  the  paroxysms.  Sometimes  only  certain 
regions  are  attacked,  especially  the  head  and  neck.  The  con(htion 
of  the  mind  is  normal  throughout;  the  eyes  are  usually  not  involved. 
In  the  acute,  rapid  cases  tiie  paroxysms  are  very  frequent  and  tiie  fever 
higli;  in  the  more  chronic  ones  incubation  is  longer,  the  periods  of  relaxa- 


516  THE  DISEASES  OF  CHILDREN 

tion  between  the  paroxysms  more  prolonged  and  complete;  and  the 
duration  of  the  attack  greater. 

Course  and  Prognosis. — The  duration  of  fatal  cases  of  tetanus  is 
seldom  more  than  3  to  4  days;  sometimes  less  than  24  hours  or  as  long 
as  6  days.  In  cases  which  recover  the  attack  may  last  several  weeks, 
the  paroxysms  gradually  diminishing  in  number  and  severity.  The 
more  severe  the  case,  the  more  rapid  is  the  course,  and  the  more  frequent 
the  paroxysms.  Death  is  the  result  of  exhaustion,  collapse,  or  of  inter- 
ference with  respiration. 

The  prognosis  of  tetanus  neonatorum  is  extremely  bad.  Death 
generally  occurs.  Probably  the  most  favorable  statistics  give  a  mor- 
tality of  nearly  50  per  cent.,  and  the  usual  death-rate  is  decidedly  greater 
than  this.  Only  the  cases  of  long  incubation  and  slow  development  of 
symptoms  offer  much  hope  from  treatment.  The  mortality  appears  to  be 
inversely  proportional  to  the  length  of  incubation.  When  under  5  days 
it  is  extremely  unfavorable;  decidedly  more  favorable  when  over  10  days. 

In  tetanus  after  the  period  of  the  new  born  the  prognosis  is  somewhat 
better,  although  still  very  grave.  The  absence  of  fever  and  the  slow  and 
late  development  of  symptoms  are  the  most  favorable  indications,  the 
prognosis  being  very  much  better  when  incubation  is  over  10  days.  The 
average  death-rate  varies  from  50  to  80  per  cent.  Involvement  of  respi- 
ration is  very  unfavorable. 

Diagnosis. — In  well-marked  cases  the  diagnosis  is  easy.  The 
disease  is  closely  simulated  by  the  convulsions  of  strychnine  poisoning, 
except  that  there  is  in  this  condition  complete  relaxation  between  the 
paroxysms,  and  that  trismus  rarely  occurs,  and  certainly  never  early. 
Severe  cases  of  tetany  sometimes  simulate  tetanus,  and  I  have  more  than 
once  seen  errors  in  diagnosis  between  the  two  diseases.  In  tetany,  how- 
ever, the  muscles  of  the  limbs  are  primarily  and  chiefly  affected,  and  in- 
volvement of  the  jaws  and  of  the  neck  seldom  or  never  occurs.  In  cases 
of  intermittent  tetany  the  periods  of  relaxation  are  much  longer  and  more 
complete  than  in  tetanus.  The  peculiar  electrical  reactions  of  tetany 
are  absent  in  tetanus.  The  history  of  the  ailment  is  often  serviceable  in 
arriving  at  a  conclusion.  I  have  seen  me^iingitis  in  rare  instances  strongly 
suggest  tetanus.  There  is,  however,  in  this  the  absence  of  trismus,  and 
the  presence  of  tenderness  on  moving  the  neck  and  of  a  disordered  mental 
state. 

Treatment.  Prophylaxis. — Most  careful  antisepsis  of  the  um- 
bilical wound  is  the  greatest  safe-guard  against  tetarms  in  the  new  born. 
In  regions  where  the  disease  prevails,  consideration  must  be  given,  too, 
to  the  character  of  the  water  employed  fo'r  the  first  washing  of  the  child, 
as  well  as  the  cleanliness  of  the  towels,  and  the  like.  When  a  case  of 
tetanus  has  occurred  in  a  lying-in  institution  careful  disinfection  of  the 
room  is  to  be  carried  out,  the  infant  isolated,  and  all  other  exposed  in- 
fants given  an  immunizing  dose  of  tetanus  antitoxin. 

Treatment  of  the  Attack. — The  first  indication  is  antiseptic  treatment 
of  the  wound,  in  order  to  prevent  further  production  of  the  poison.  The 
patient  should  be  handled  very  little  and  kept  as  quiet  as  possible  in  a 
darkened  room,  in  order  to  diminish  the  tendency  to  paroxysms.  Drugs 
to  quiet  the  nervous  system  should  be  given  in  frequently  repeated  doses, 
large  enough  to  produce  some  physiological  effect.  Chloral  is  one  of  the 
best  for  this  purpose.  A  child  of  2  years  may  begin  with  2  or  3  grains 
(0.13  to  0.19)  every  hour,  the  amount  to  be  increased  if  necessary.  Potas- 
sium bromide  is  another  valuable  remedy,  the  dose  at  2  years  being  8  to 


ACUTE  POLIOMYELITIS  517 

10  grains  (0.52  to  0.65) ,  or  eventually  more,  every  2  houi'S.  When  swallow- 
ing is  impossible,  remedies  may  be  administered  by  the  bowel  or  through  a 
nasal  tube.  Physostigma  has  long  been  a  favorite  remedy.  Its  alka- 
loid, eserin,  may  be  given  hypodermically  in  doses  of  I500  of  a  grain 
(0.00013)  at  this  age,  repeated  as  needed.  It  is  to  be  borne  in  mind  that 
both  chloral  and  eserin  are  depressant  remedies.  This  statement  merely 
indicates  the  necessity  of  care  in  their  employment,  not  avoidance  of 
them.  Morphine  hypodermically  may  be  useful.  The  administration 
of  an  anesthetic  may  be  necessary  during  the  paroxysms  if  they  are 
severe.  Feeding  is  important  and  may  be  accomplished  by  the  rectal 
or  nasal  tube  if  the  ability  to  swallow  has  ceased. 

In  recent  years  the  value  of  magnesium  sulphate  for  the  control  of 
the  spasms  appears  to  have  been  thoroughly  demonstrated.  It  should 
be  administered  subcutaneously,  and  in  severe  cases  intraspinally  or 
intravenously.  For  subcutaneous  injection  the  dose  should  be  0.6  to 
0.8  c.c.  (9  to  13  m.)  of  a  25  per  cent,  solution  per  kilogram'  of  body 
weight,  3  or  4  times  a  day  (Meltzer).i  For  intraspinal  and  intravenous 
administration  the  solution  should  be  weaker  and  the  dosage  much 
smaller.  A  survey  of  the  reported  cases  in  which  the  treatment  has  been 
tried  is  given  by  Robertson. ^  The  treatment  is  not  without  danger  of 
producing  respiratory  paralysis. 

Antitoxin  Treatment. — In  1890  Behring  and  Kitasato^  were  able  to 
immunize  rabbits  against,  or  to  cure  them  of,  tetanus,  by  injecting  a 
tetanus  antitoxin,  and  soon  afterward  antitetanic  serum  was  employed 
in  man  and  has  been  used  repeatedly  since  that  time.  The  results  on 
the  whole  have  been  unsatisfactory,  due  probably  to  the  fact  that  by  the 
time  symptoms  appear  the  toxic  condition  of  the  central  nervous  system 
is  already  too  advanced  to  be  modified  by  treatment.  In  the  severe 
cases  it  seems  of  no  more  value  than  other  plans  of  treatment,  and  in  the 
more  chronic  ones  with  better  prognosis  other  methods  seem  equally 
serviceable.  To  be  of  use  it  should  be  administered  as  early  in  the  dis- 
ease as  possible,  the  dose  varying  with  the  preparation,  and  being  still 
unsettled.  My  only  experience  with  it  has  been  in  subacute  cases  where 
sedative  drugs  were  employed  as  well.  In  tetanus  neonatorum  isolated 
cases  of  recovery  have  been  reported  under  this  treatment,  and  there 
are  tliosc*  who  consider  it  of  undoubted  value  even  when  SA'mptoms  have 
already  developed.  The  antitoxin  should  be  given  subcutaneously  or 
intraspinally  and  intravenously,  and  the  treatment  should  certainly  be 
tried  whenever  possible.  There  is  good  reason  to  believe  that  the  serum 
is  of  value  when  given  as  a  preventive  measure  to  infants  who  have  been 
exposed. 

CHAPTER  XVIII 

ACUTE  POLIOMYELITIS 

(Acute  Infantile  Paralysis;  Meningo-encephalo-myelitis) 

History. — -There  have  been  in  the  lust  few  years  such  changes  in  our 
knowledge  of  this  disease  that  we  are  now  forced  beyond  question  to  place 
it  among  the  acute  infectious  disorders. 

We  have  no  account  of  it  until  that  of  Underwood^  in  1784,  who, 

1  Jour.  Amcr.  Med.  Assoc,  191(5,  LXVI,  931. 

2  Arch,  of  Int.  Med.,  1916,  XVII,  077. 

3  Deut.  med.  Wochenschr.,  1890,  XVI,  1113. 

•*  See  Irons,  Jour.  Amer.  Med.  Assoc,  1915,  LXIV,  1652. 
*  Diseases  of  Children,  1789,  Second  edition,  II,  53. 


518 


THE  DISEASES  OF  CHILDREN 


however,  confessed  entire  ignorance  of  its  cause  and  considered  it  not  a 
common  disorder.  It  was  not  until  1840  that  a  satisfactory  description 
was  given  of  it  by  J.  Heine. ^  The  disease  was  called  the  ''essential 
paralysis  of  children"  by  Rilliet  and  Barthez^  in  1843.  The  association 
with  lesions  of  the  anterior  horns  of  the  spinal  cord  was  shown  by  Prevost-^ 
in  1865  and  afterward,  as  a  result  of  careful  investigations,  by  Charcot 
and  Joffroy^  in  1870.  The  first  study  of  its  epidemic  relations  was  made 
in  Norway  and  Sweden  especially  by  Medin.*  As  a  result  some  writers 
follow  Wickman*^  in  naming  it  the  "Heine-Medin  disease."  Upon  the 
.  basis  of  the  newer  recognition  of  its  pathology  it  is  properly  denominated 
meningo-encephalo-myelitis,  but  as  this  name  is  cumbersome  the  older 
title  "poliomyelitis"  (ttoXios,  grey)  may  be  retained  as  representing  the 
more  common  seat  of  the  lesion;  or  that  of  "acute  infantile  paralysis," 
since  the  great  majority  of  cases  of  acute  paralysis  in  early  life  are  to  be 
classified  here. 

Formerly  a  malady  of  no  great  frequency  as  compared  with  many 
others,  in  more  recent  years  its  prevalence  has  increased  enormously  and 
the  disease  has  taken  its  place  among  the  common  and  serious  disorders 
of  early  life. 

Etiology.  Predisposing  Causes,  ^ — Of  the  predisposing  causes, 
age  is  of  great  importance.  The  great  majority  of  cases  occur  between 
the  ages  of  1  and  5  years  and  especially  in  the  2d  year  of  life.  The  follow- 
ing table  by  Frost, ^  illustrates  this  well: 

Table  71. — Incidence  of  Poliomyelitis — United  States 


New  York 

Commission 

729  cases 

percentage  of  total 


Massachusetts     |  Minnesota 

Commission  Commission 

615  cases  ]  324  cases 

percentage  of  totalipercentage  of  total 


Under  1  j-ear. . 

1  to    5  years. 

6  to  10  j^ears. 
11  to  15  years. 
16  to  20  years. 
Over  20  years  .• 


8.50 
82.00 
6.40 
1.90 
0.68 
0.40 


7.20 
64.50 
15.90 

5.00 

2.4 

5.0 


6.50 
48.60 
23.70 
7.70 
6.50 
7.0 


European  statistics  give  similar  figures,  although  the  percentage 
among  adults  is  somewhat  increased.  This  is  well  shown  in  the  following 
table  condensed  from  one  given  by  Wickman.^ 

Table  72. — Incidence  of  Poliomyelitis — Sweden 


0  to    3  years 

3  to    6  years . 

6  to    9  years . 

9  to  12  years. 
12  to  15  years. 
Over  15  years. 


1025  Cases 
percentage  of  total 

17.85 
20.88 
17.46 
12.00 
10.35 
21.46 


'  Beobachtungen    ii.   Lahmungszustande   der   unlcren  Extremataten.    Stuttgart, 
1840. 

2  Maladies  des  enfants,  1843,  II,  335. 

'  Comptes  rend,  de  la  soc.  de  biol.,  1865,  II,  215. 

''  Arch,  de  phvsiol.  norm,  et  pathol.,  1870,  III,  132. 

5  Nord.  Med.'Arkiv.,  1896,  VI,  No.  1. 

^  Beitrage  zur  Kentniss  der  Heine-Medinschen  Krankheit,  1907. 

'  PubUc  Health  BuUetin,  1911,  No.  44. 

*  Die  acute  Poliomyelitis,  Berlin,  1911,  11. 


ACUTE  POLIOMYELITIS  519 

Although  less  common  in  the  1st  year,  it  may  exceptionally  occur  even 
in  very  early  life.  Sinkler^  observed  1  case  developing  at  6  weeks,  and  2 
at  3  months;  and  still  younger  cases  are  recorded.  A  comparative  study 
of  the  reports  of  a  number  of  observers  show  a  slight  preponderance  of 
the  disease  among  males  (Wickman).- 

Season  also  is  an  important  predisposing'^factor.  Everywhere  the 
majority  of  cases  occur  in  the  summer  time,  the  height  of  an  epidemicjin 
the  northern  hemisphere  being  July,  August  and  September,  the  number 
diminishing  rapidly  after  this;  in  the  southern  hemisphere  February, 
March  and  April.  Geograj)hical  position  has  no  real  influence,  for 
although  some  parts  of  the  world  have  suffered  from  it  much  more  than 
others,  the  disease  is  now  widely  spread.  Residence  and  social  position 
are  without  much  influence,  poliomyelitis  occurring  in  both  cities  and 
rural  districts,  although  somewhat  more  frequent  in  the  latter  in  pro- 
portion to  the  population.  Other  circumstances  were  formerly  supposed 
to  predispose,  such  as  the  occurrence  of  other  infectious  disorders,  ex- 
posure to  cold,  over  exercise,  and  the  like;  but  their  influence  seems 
problematical.  The  individual  susceptibility  is  not  great.  The  majority 
of  those  exposed,  as  far  as  this  can  be  determined,  do  not  contract  the 
disorder.  Herrman^  estimates  that  only  about  2  per  cent,  of  children 
exposed  acquire  the  disease.  It  is  unusual  that  more  than  one  child 
in  a  family  is  affected.  To  this  there  are  exceptions,  however,  especially 
during  epidemics.  Notable  here  is  the  record  of  the  Swedish  epidemic, 
in  which  repeatedly  more  than  one  child  in  a  house  was  attacked  by  the 
disease.  Of  1031  cases  reported  by  Wickman"  627  houses  had  1  case 
each;  95  houses  2  cases  each;  39  houses  3  cases;  14  houses  4  cases;  7  houses 
5  cases;  1  house  6  cases. 

The  epidemic  influence  has  already  been  alluded  to.  Early  in  its 
history  poliomyelitis  occurred  chiefly  sporadically,  and  no  thought  of  its 
infectious  or  epidemic  nature  was  entertained.  The  first  local  epidemic 
recorded  appears  to  have  been  one  of  8  or  10  cases  in  a  rural  region  of 
Louisiana  reported  by  Colmer.^  The  first  epidemic  in  Norway  is  said  by 
Harbitz*^  to  have  consisted  of  14  cases  observed  by  Bull  in  1868.  After 
this,  at  intervals,  small  epidemics  were  recorded  in  different  parts  of  the 
world,  each  confined  to  a  small  area  and  limited  in  number;  much  the 
largest  being  in  the  Otter  Creek  Valley  of  Vermont  in  1894,  with  123 
cases  (Calverly).''''  There  were  frequent  local  outbreaks  in  Scandinavia. 
In  1887  an  epidemic  of  43  cases  occurred  in  Stockholm  and  was  fully 
described  by  Medin.'-*  In  1905  the  disease  became  rather  widespread  over 
Norway  and  Sweden — 719  cases  being  recorded  by  Harbitz  and  SchecP" 
in  Norway  and  1025  cases  by  Wickman"  in  Sweden.  Up  to  1907  Holt  and 
Bartlett'2  were  able  to  collect  a  total  of  35  reported  epidemics,  chiefly 
small,  numbering  in  all  about  2000  cases;  the  majority  of  these  in  Scandi- 

1  Keating's  Cyclopedia  Diseases  of  Children,  1890,  IV,  685. 

2  Die  acute  Poliomvelitis,  1911,  12. 

3. Jour.  Amcr.  Med.' Assoc,  1917,  LXIX,  103. 

■•  BeitriiKc  zur  Kentniss  der  Heine-Medinschen  Krankheit,  1907,  267. 
6  Amer.  Journ.  Med.  Sciences,  1843.  V,  248. 
6  Journ.  Amer.  Med.  Assoc,  1912,  LIX,  782. 
->  Yale  Med.  Journ.,  1894,  I,  1. 

*  A  later  report  (Journ.  Amer.  Med.  Assoc,  1896,  XXVI,  1)  gives  the  number  of 
cases  as  132. 

9  Nord.  Med.  Ark.,  1896,  VI,  No.  1. 

1"  Die  acute  PoUoniyelitis  u.  verwandte  Ivrankheiten,  1907. 
'1  Beitriige  z.  Kentniss  der  Heine-Medinschen  Krankheit.,  1907. 
»2  Amer.  Journ.  Med.  Sci.,  1898,  CXXV,  647. 


520  THE  DISEASES  OF  CHILDREN 

navia.  After  this  year  the  number  of  epidemics  and  the  total  number  of 
cases  increased  rapidly.  In  1907  about  2500  cases  occurred  in  New  York 
City  and  vicinity.^  In  1909  the  disease  spread  rapidly  over  many  parts 
of  the  United  States,  approximately  over  9000  cases  in  43  different  States 
being  reported  in  1910  (Lovett  and  Richardson).'^  Meanwhile  other 
epidemics  of  less  size  were  observed  in  Australia,  Scandinavia,  England, 
Denmark,  Cuba,  Canada,  Germany,  and  elsewhere,  but  nothing  to  be 
compared  with  the  frequency  of  the  disease  in  the  United  States,  with 
the  exception  of  Scandinavia.  Here,  according  to  Wernstedt,"''  a  second 
great  epidemic  occurred  in  Sweden,  from  the  beginning  of  1911  to  Sep- 
tember 15,  1912  more  than  6000  cases  being  reported;  while  in  Norway  in 
1911,  Johannessen^  states  there  were  not  less  than  1407  cases.  In  the 
summer  of  1916  another  very  large  epidemic  occurred  in  the  United 
States,  chiefly  in  the  northeastern  portion,  the  principal  locality  being 
New  York  City  and  vicinity,  in  the  city  itself  nearly  9000  cases  being 
reported.  In  the  same  summer  about  1000  cases  occurred  in  Phila- 
delphia (Le  Boutillier)."  In  all  there  were  about  24,000  cases  in  the 
United  States  in  this  epidemic  (Emerson).^  In  1917  there  were  at  least 
35,000  cases  in  the  United  States  (Lavinder).'' 

Exciting  Cause. — That  the  disease  is  an  infectious  one  seems  to 
have  been  first  suggested  by  Striimpell,*  and  all  recent  clinical  experience 
together  with  animal  experimentation  has  proven  the  truth  of  this.  The 
nature  of  the  infectious  element,  however,  has  not  been  at  all  understood 
until  within  a  few  years.  Of  the  many  earlier  bacteriological  investiga- 
tions, one  of  the  most  important  was  made  by  Geirsvold'*  who  described 
a  diplococcus  found  in  the  spinal  fluid  and  the  organs.  Yet  later  inves- 
tigations show  that,  whatever  its  significance,  this  is  not  the  causative 
factor.  In  1909  Landsteiner  and  Popper^"  injected  into  the  peritoneal 
cavity  of  two  monkeys  the  emulsified  spinal  cord  of  a  fatal  case  of  polio- 
myelitis, and  succeeded  in  producing  the  disease  in  these  animals.  In 
the  same  year  Flexner  and  Lewis^^  also  produced  the  disease  in  monkeys, 
and  were  able  in  addition  to  transmit  it  indefinitely  through  a  series  of 
these  animals.  Later  studies  by  Flexner  and  Lewis^-  showed  that  the 
virus  was  filterable,  passing  through  a  porcelain  filter  and  consequently 
containing  a  germ  which  necessarily  is  exceedingly  minute.  That  it  is, 
however,  a  true  germ  was  proven  by  the  fact  that  the  virus  is  destroyed 
by  heat  and  by  weak  disinfectant  solutions,  such  as  peroxide  of  hydrogen, 
permanganate  of  potash,  and  menthol ;  and  that  it  required  a  certain  in- 
cubative time  in  animal  experimentation  for  the  development  of  symp- 
toms. It  withstands  the  action  of  glycerine  and  of  freezing;  and  Romer 
and  Joseph^^  found  that  it  resisted  the  effect  of  drying  for  as  long  as  28 
days.     The  virus  has  not  been  successfully  transmitted  to  other  animals 

1  Report  on  the  New  York  Epidemic ;  by  fhe  Collective  Investigation  Committee, 
1910,  27. 

2  Infantile  Paralysis  in  Massachusetts  during  1910,  55;  57. 

3  Jahrb.  f.  Kinderh.,  1912,  LXXVI,  605. 
*  Jahrb.  f.  Kinderh.,  1912,  LXXVI,  603. 

5  Amer.  Journ.  Med.  Sci.,  1917,  CLIII,  188. 
«  Bull.  Johns  Hopk.  Hosp.,  1917,  XXVIII,  131. 
'  Bost.  Med.  and  Suig.  Journ.,  1918,  CLXXVIII,  747. 
^  Jahrb.  f.  Kinderh.,  1885,  XXII,  173. 
9  Norsk.  Magazin  for  Laegevidskaben,  1905,  LXVI,  1280. 
1"  Zeitsch.  f.  Immunitatsforschung,  Orig.,  1909,  377. 
u  Journ.  Amer.  Med.  Assoc,  1909,  LIII,  1639. 

12  Journ.  Amer.  Med.  Assoc,  1909,  LIII,  2095. 

13  Miinch.  med.  Wochenschr.,  1910,  LVII,  568,  945.     , 


ACUTE  POLIOMYELITIS  521 

than  monkej^s,  with  the  possible  exception  of  rabbits  (Krause  and 
Meinicke).^  Most  investigators  deny  the  transmissibihty  to  the  latter 
animals.  The  virus  is  contained  in  the  brain  and  spinal  cord,  salivary 
and  lymphatic  glands,  tonsils,  nasopharyngeal  and  oral  mucous  membrane, 
intestines,  and,  early  in  the  attack  and  to  a  very  limited  extent,  in  the 
blood  and  cerebrospinal  fluid.  It  can  be  transmitted  experimentally  by 
inoculation  into  various  regions  of  the  body,  including  the  brain,  spinal 
cord,  peritoneum  and  subcutaneous  tissue,  and  can  be  given  by  intro- 
ducing it  into  the  stomach  and  intestines  or  by  rubbing  it  upon  the  nasal 
mucous  membrane.  The  monkeys  never  acquire  it  from  each  other  by 
mere  association.  It  has  been  found  to  persist  on  the  nasal  mucous  mem- 
brane of  the  animal  for  as  long  as  5}i  months  after  the  attack  is  over. 
Osgood  and  Lucas-  and  Pettersson,  Kling  and  Wernsteclt^  have  found 
it  in  the  washings  from  the  nose  of  parents  and  other  attendants  upon 
the  patient  even  7  months  after  the  occurrence  of  the  attack.  The 
question  of  the  actual  nature  of  the  virus  is  brought  nearer  solution  by 
the  discovery  in  1913  by  Flexner  and  Noguchi*  in  cultures  and  in  the 
tissues  of  the  brain  and  spinal  cord  of  very  minute  globoid  bodies  in  which 
the  power  of  infection  appears  to  reside,  and  which  would  seem  to  be 
the  actual  germ  of  the  disease.  It  is  believed  by  Rosenau,  Towne  and 
Wheeler,^  Nuzum  and  Herzog^  and  others  that  the  globoid  bodies  are 
but  a  small  form  of  a  streptococcus  which  they  have  found  in  the  cen- 
tral nervous  system  of  monkeys  experimentally  infected  with  the  disease. 
Whether  or  not  the  streptococcus  is  only  a  secondary  infection  is  not  yet 
definitely  determined. 

Method  of  Transmission.  Infectivity. — The  method  of  transmission 
in  human  beings,  and  the  degree  of  infectiousness  are  not  clearly  under- 
stood. It  is  probable  that  the  virus  enters  the  system  by  way  of  the 
nose — or  perhaps  the  intestine — -being  acquired  from  the  nasal  mucous 
membrane  of  an  affected  individual.  Flexner 's  and  Amoss'^  experi- 
ments support  the  view  that  it  reaches  the  nervous  system  by  waj'  of  the 
lymph-channels  and  without  involvement  of  the  blood,  and  that  the 
portal  of  entry  appears  to  be  the  mucous  membrane  of  the  upper  re- 
spiratory tract. 

The  conditions  obtaining  are  very  like  those  seen  in  cerebrospinal 
fever.  In  both  diseases  widespread  epidemics  may  oqcur  and  the 
infectivity  appear  to  be  much  increased;  or  the  disease  may  develop 
sporadically  and  seem  to  be  but  little  infectious.  Both  are  transmitted 
in  some  way  from  the  sick  to  the  well,  and  probably  either  directly  or 
indirectl}^,  yet  usually  not  more  than  one  case  occurs  in  a  famih',  and 
cases  of  either  disease  treated  in  hospitals  do  not  transfer  the  infection 
to  others  in  the  ward. 

That  poliomj^elitis  may  be  transmitted  bj'-  unaffected  persons  acting 
as  carriers  has  been  shown  in  many  instances,  notably  in  the  local 
epidemics  reported  by  Wickman^  in  Trastena  in  Sweden,  and  by  Shidler^ 
in  York,  Nebraska,  respectr/ely.     It  is  uncertain  how  frequently  trans- 

'  Deutsch.  mcd.  Wochenschr.,  1909.  XXXV,  1825. 

2  Journ.  Ainer.  Med.  Assoc,  1911,  LVI,  495. 

•'  15th  Intern.  Cong.  Hyg.  and  Ueinog.,  1912, 1,  597. 

^  Journ.  Amer.  Med.  Assoc,  19V,i,  LX,  362. 

^  Journ.  Amer.  Med.  Assoc,  1910,  LXVII,  1202. 

«  Journ.  Amer.  Med.  Assoc,  1916,  LXVII,  1205;  1437. 

^  Journ.  Exper.  Med.,  1914,  XX,  249. 

8  Beitriige  z.  Kentniss  der  Heine-Medicinschen  Krankheit.,  1907,  150. 

»  Journ.  Amer.  Med.  Assoc,  1910,  LIV,  277. 


522  THE  DISEASES  OF  CHILDREN 

mission  occurs  in  this  way.  Very  rarely  cases  have  developed  after 
occupying  a  house  which  had  recently  sheltered  a  patient;  yet  generally 
it  is  impossible  to  trace  the  origin  of  any  case  to  contact  with  some 
previous  one.  This  raises  the  question  of  the  possibility  of  the  spread 
of  the  disease  by  such  other  agencies  as  dust  (Neustaedter  and  Thro),^ 
bed  bugs,  (Howard  and  Clark),-  houseflies  (Flexnerand  Clark), ^domestic 
animals  and  the  like.  That  some  or  all  of  these  are  factors  of  importance 
is  possible.  Rosenau*  is  confirmed  by  Anderson  and  Frost^  in  his  belief 
that  the  infection  is  communicated  chiefly  by  the  bite  of  the  stable-fly. 
That  it  is  given  by  the  bite  of  this  or  any  other  insect  has,  however,  been 
disputed  by  most  investigators. 

At  what  period  of  the  disease  the  infectiousness  is  greatest  is  still 
unknown.  That  it  may  persist  for  a  considerable  time  after  convales- 
cence has  already  been  pointed  out  (53^2  months;  Osgood  and  Lucas). 

Pathological  Anatomy. — This  has  been  studied  with  especial 
care  in  human  beings  by  Wickman^  and  by  Harbitz  and  Scheel  ;^  and  in 
monkeys  by  Langsteiner  and  Popper,^  Flexner^  and  others.  In  brief, 
there  is  a  disseminated  lymphocytic  infiltration  of  the  pia  and  of  all 
parts  of  the  central  nervous  system,  but  chiefly  in  most  instances  of  the 
grey  matter  of  the  cord,  especially  in  the  anterior  horns.  The  changes 
are  most  marked  in  the  lumbar  and  cervical  enlargements.  The  earliest 
alterations  in  the  spinal  cord  consist  of  congestion  of  the  blood-vessels 
of  the  pia  and  nervous  tissue,  with  small-celled  infiltration  and  edema. 
Hemorrhages,  small  or  more  diffuse,  sometimes  occur  into  the  grey 
matter.  These  changes  are  rapidly  followed  by  degeneration  and  dis- 
appearance of  the  ganglion  cells  of  the  grey  matter,  the  result  of  the 
pressure  by  the  inflammatory  exudate  and  edema  with  the  consequent 
interference  with  the  circulation.  The  degree  and  extent  of  the  affection 
of  the  ganglion  cells  varies  greatly,  dependent  upon  the  degree  of  involve- 
ment of  the  blood-vessels  and  of  the  general  small-celled  infiltration. 
In  some  cases  but  few  cells  are  involved;  in  others  none  at  all  can  be 
found  remaining  in  certain  regions. 

The  white  matter  of  the  cord  shows  similar  congestion,  edema,  and 
infiltration  of  the  perivascular  spaces,  although  to  a  much  less  extent, 
with  small  foci  of  cellular  infiltration  in  the  white  matter  itself.  Changes 
like  those  in  the  white  matter  are  seen  in  the  spinal  ganglia  and  some- 
times in  the  anterior  nerve-roots.  In  the  medulla  and  pons  there  are 
lesions  similar  to  those  in  the  cord,  but  usually  with  less  degeneration 
of  the  ganglion  cells.  The  cerebellum  and  cerebral  hemispheres  are  not 
so  often  involved,  but  the  changes  resemble  those  described,  consisting 
of  congestion  and  hemorrhages,  with  small-celled  infiltration  of  the  peri- 
vascular spaces  and  of  areas  of  the  brain-tissue  itself.  As  already  stated, 
the  anterior  horns  of  the  lumbar  and  cervical  enlargements  of  the  cord 
are  the  favorite  seat  of  the  lesions  found;  but  the  process  is,  in  fact,  a 
diffuse  one,  involving  perhaps  the  entire  cord,  the  meninges  of  the 
brain  and  cord,  and  many  parts  of  the  brain  itself  as  well.     Further, 

1  Journ.  Amer.  Med.  Assoc,  1912,  LIX,  785. 
■-'  Journ.  Exper.  Med.,  1912,  XVI,  850. 
3  Journ.  Amer.  Med.  Assoc,  1911,  LVI,  1717. 
<  Journ.  Amer.  Med.  Assoc,  1912,  LIX,  1314. 
5  U.  S.  Public  Health  Rep.,  1912,  XXVII,  pt.  2,  1733. 

8  Studien    ii   Poliomj^elitis    acuta.    Arbeiten   aus   dem   path.    Inst.  d.  Universit. 
Helsingfors,  1905,  I,  109. 

'  Path.-anatom.    Untersuch.    ii.  akute  Poliomyelitis  ii.  verwandt.  Krankh.,  1907. 

8  Zeitsch.  f.  Immunitatsforsch.,  Orig.,  1909,  II,  377. 

9  Jour   Amer.  Med.  Assoc,  1910,  LV,  1105. 


ACUTE  POLIOMYELITIS  523 

exceptions  to  the  usual  distribution  are  not  infrequent,  and  the  medulla, 
cerebellum,  or  cerebrum  may  suffer  to  a  greater  extent  than  the  spinal 
cord. 

Other  organs  show  alterations  in  acute  cases,  these  consisting  of  degen- 
erative changes,  such  as  are  seen  in  any  infectious  disorder,  and  situated 
especiall}^  in  the  liver,  lungs,  kidneys  and  myocardium.  Hyperplasia 
of  the  lymphoid  tissue  of  the  intestine,  spleen  and  mesenteric  glands  is 
common.  The  spleen,  lymphatic  glands  and  thj'mus  may  be  much 
enlarged.     Swelling  of  the  tonsils,  with  purulent  secretion,  is  frequent. 

In  cases  of  long-standing,  autopsy  shows  the  affected  portion  of  the 
spinal  cord  shrunken  and  the  nervous  tissue  replaced  by  sclerotic  tissue 
and  neuroglia.  The  anterior  nerve-roots  and  the  muscles  exhibit  de- 
generative changes  and  atrophy,  fatty  and  connective  tissue  replacing 
the  muscular  fibres.  The  degree  of  these  secondary  nervous  and  mus- 
cular lesions  corresponds  to  that  of  the  primary  involvement  of  the  spinal 
cord.  Consequently  in  the  milder  cases  entirely  healthy  nervous  and 
muscular  fibres  may  be  found  associated  with  those  more  or  less  atrophied. 

Symptoms. — A  number  of  distinct  types  have  been  described  in 
addition  to  the  ordinary  spinal  form  which  has  long  been  well  recognized. 
Of  the  various  classifications  proposed,  one  frequently  adopted  is  that  of 
Wickman^  which  divides  the  types  into:  (1)  Ordinary  spinal  form;  (2) 
progressive  form;  (3)  bulbar  form;  (4)  acute  encephalitic  form;  (5) 
ataxic  form;  (6)  meningitic  form;  (7)  polyneuritic  form;  (8)  abortive 
form.  These  types  shade  into  each  other,  or  may  be  combined  to  such 
an  extent  that  a  sharp  differentiation  may  be  impossible. 

1.  Spinal  Form. — With  the  exception  of  the  abortive  form  this  is 
much  the  most  frequent  variety,  88.65  per  cent,  of  Zappert's^  555  cases 
belonging  to  this  category.  Many  of  the  statements  which  follow  upon 
such  topics  as  incubation,  method  of  invasion,  mortality,  and  many  of 
the  symptoms  of  the  attack,  and  its  duration  and  prognosis  apply  equally 
well  to  all  forms  of  the  disease. 

Incubation. — This  would  appear  to  average  a  week  or  less,  with  a 
i"ange  of  from  5  to  10  days  or  exceptionally  shorter  or  longer.  In  experi- 
mental work  upon  monkeys  the  incubation  may  vary  through  a  still 
greater  range.     There  are  no  symptoms  during  this  period. 

Stage  of  Invasion. — The  onset  is  usually  sudden,  with  fever,  head- 
ache, prostration,  and  occasionally  convulsions;  as  may  occur  in  any  of 
the  infectious  diseases.  Vomiting  is  a  frequent  early,  or  even  initial 
symptom,  but  is  seldom  often  repeated.  Constipation  is  the  rule, 
but  in  some  cases  there  is  very  severe  diarrhea.  The  combination  of  the 
latter  with  vomiting  is  suggestive  of  some  gastrointestinal  affection.  In 
man}'  cases  respiratory  symptoms  predominate,  with  coryza,  conjunc- 
tivitis, or  bronchitis,  and  including  sore  throat.  Respiratt)ry  symptoms 
were  most  prominent  in  over  half  of  Miiller's^  cases,  but  in  the  400  cases 
analyzed  by  Wilson*  they  were  not  of  frequent  occurrence.  Decided 
general  hyperesthesia,  sweating,  and  groat  nervous  irritability  are  com- 
mon and  suggestive  and  headache  is  gencMally  present.  The  mind  may 
be  clear  or  there  may  be  somnolence  or  occasionally  coma.  An  early 
persistent  drowsiness  was  present  in  72  per  cent,  of  Wilson's  series.  It 
is  accompanied  often  by  a  remarkable  degree  of  irritability  when  the 

1  Beitriige  z.  Kentni.s.s  dor  Hcino-!Modiiisohon  Kranklicit,  1007,  10. 
-  Studion  ii.  d.  Heino-Modiiischo  Kraiiklicit,  1!U1,  M. 
^  E.  Miiller,  Die  Spinale  Kiiulorlaliniung,  Berlin,  11)10. 
*  Arch,  of  Pediat.,  1916,  XXXIIl,  850. 


524 


THE  DISEASES  OF  CHILDREN 


child  is  disturbed.  There  is  verj^  commonly  tenderness  and  stiffness 
of  the  neck  and  back,  and  pain  on  moving  the  body.  The  tendon-reflexes 
may  in  some  cases  be  temporarily  increased,  but  are  soon  lost.  The 
temperature  varies,  ranging  from  102°  to  103°F.  (38.9°  to  39.4°Co.)  or  occa- 
sionally higher;  sometimes  continuous;  sometimes  remittent;  sometimes 
falling  when  the  paralysis  appears;  and  continuing  from  1  to  10  days  (Fig. 
162)  with  an  average  of  4  days  (Wilson)^  and  falling  by  lysis  or  by  crisis. 
In  the  mildest  cases  fever  may  be  slight  and  of  short  duration  or  occa- 
sionally absent.     Yet,  on  the  other  hand,  severe,  fatal  cases  may  exhibit 


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Fig.  162. — Poliomyelitis,  Ordinary  Spinal  Form. 
S.  D.,  girl,  aged  6  years.  Aug.  9,  taken  ill  with  loss  of  appetite,  restlessness,  con- 
stipation, tenderness  and  rigidity  in  neck,  sweating  of  head,  twitching  and  fever;  Aug.  10, 
fever  continued,  weakness  in  both  legs;  Aug.  11,  both  legs  absolutely  paralyzed.  Cere- 
brospinal fluid  obtained  under  no  pressure  showed  36  cells  to  the  c.  mm.  {Courtesy  of  Dr. 
M.  Ostheivier.) 

Fig.  163. — Poliomyelitis  with  Little  Fever.     Death. 
Boy,    aged   4   months.     Extensive   paralysis.     Death   on    the  4th  day.     {Wickmann, 
Beitrdge  z.  Kentniss  d.  Heine-Medinsch.  Krankh.,  1907;  15.) 

but  little  rise  of  temperature  (Figs.  163  and  166)  and  those  of  much  less 
severity  may  run  a  high  febrile  course  (Fig.  164).  The  temperature  in 
this  disease  is,  in  fact,  entirely  uncharacteristic.  (See  temperature 
charts.)  Yet  more  or  less  elevation  of  temperature  is  nearly  always 
present.  The  pulse  is  accelerated,  often  out  of  proportion  to  the  fever. 
The  urinary  functions  are  generally  undisturbed,  but  retention  is  not  infre- 
quent, while  incontinence  is  uncommon.  Zingher^  has  pointed  out  the  fact 
that  there  is  an  unusual  susceptibihty  to  the  Shick  test  in  subjects  with 

^  Loc.  cit. 

2  Amer.  Jour.  Dis.  Child.,  1917,  XIII,  247. 


ACUTE  POLIOMYELITIS 


525 


poliomj'elitis.  Examination  of  the  hlood  gives  inconstant  results.  Occa- 
sionally there  is  decided  leucopenia,  with  slight  increase  of  the  lympho- 
cytes; but  oftener  this  condition  is  absent  and  there  is  a  moderate  or  even 
decided  leucocytosis.  Examination  of  the  spinal  fluid  of  the  monkey 
24  hours  after  inoculation,  as  demonstrated  by  Flexner  and  Lewis/ 
and  of  human  cases  very  early  in  the  prodromal  stage  shows  a  moderate 
increase  in  the  number  of  cells,  especially  those  of  the  polymorphonuclear 
type,  which  equal  80   per  cent,  or  90  per  cent,  of  the  total  number. 

Promptly,  however,  before  paralysis  

develops,  the  lymphocytes  become 
predominant  and  soon  number  90 
per  cent,  or  more  of  the  cellular 
element.  The  total  number  of  cells 
ranges  from  15  or  20  up  to  100,  or 
exceptionally  much  more  in  the 
cubic  millimeter;  in  contradistinc- 
tion to  normal  serum  which  contains 
only  5  or  10  cells.  The  fluid  is  clear 
or  opalescent,  forms  a  fibrin  clot  in 
some  instances  (Kolmer,  et  al.y 
and  exhibits  a  moderate  reaction 
for  globulin.  There  is  a  prompt 
reduction  of  Fehling's  solution. 
The  cellular  increase  rapidly  dimin- 
ishes after  paralysis  has  become 
evident,  and  by  the  end  of  the  2d 
week  the  numbers  are  normal. 
The  globulin  diminishes  rather 
more  slowly. 

The  duration  of  the  period  of 
invasion  varies.  The  average  may 
be  placed  at  3  or  4  days,  but  there 
are  many  instances  in  which  the 
prodromal  symptoms  are  wanting, 
or  so  slight  that  they  have  been 
overlooked,  and  the  paralysis  comes 
on  suddenl}'  while  the  child  is 
walking  or  sitting.  In  other  cases 
the  constitutional  symptoms  last 
only  during  the  night  and  the 
child  is  found  to  be  paralyzed  in 
the  morning.  In  still  others  symptoms 
l)efore  the  paralysis  appears.     It 


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Type. 


164. — Poliomyelitis,  Spinal 
Severe  Initial  Symptoms. 
E.  D.,  male,  aged  2  years.  Taken  ill 
with  loss  of  appetite,  fever,  great  restlessness, 
profuse  sweating,  hyperesthesia  and  pain  on 
passive  movement,  slight  angina.  Paralysis 
appeared  on  the  3d  day.  Recovered  with 
residual  paralysis.  (Miiller,  Die  spinale 
Kinderldhmuna,  1910,  45;  74.) 


may  continue  for  a  week 
has  been  pointed  out  by  KHng  and 
Levaditi^  that  there  is  not  infrequently  a  free  interval  of  from  1  to  3 
days  between  certain  transitory  uncharacteristic  symptoms  and  the 
onset  of  what  are  generally  regarded  as  the  symptoms  of  invasion. 

Stage  of  Acute  Paralysis. — At  the  close  of  the  .stage  of  invasion  pa- 
ralysis shows  itself;  generally  at  first  as  a  decided  weakness  of  some  of  the 
muscles,  but  inci'easing  in  degree  and  extent  during  3  or  4  days.  Excep- 
tionally the  development  is  much  .slower  than  this.     The  regions  affected 


1  Journ.  of  Expor.  Med.,  1910,  March.  227. 

2  Anier.  .Jour.  Med.  Sei.,  1917,  CLIV,  720. 

3  Pub.    de    I'institut    Pasteur    de  Paris,   1913. 
1917,  XXXIV,  401. 


Kef.,    llavnes.    .\reli.  of    Pediat., 


526  THE  DISEASES  OF  CHILDREN 

vary  greatly.  Much  most  frequently  the  paralysis  is  situated  in  one  or 
both  legs,  the  parts  below  the  knee  being  oftener  or  more  severely 
involved  than  those  above.  Not  all  the  muscles  of  the  limbs  are  affected, 
the  peroneal  muscles  and  the  tibialis  anticus  and  posticus  being  especially- 
prone  to  be  attacked.  So,  too,  not  all  the  fibres  of  any  muscle  partici- 
pate in  the  process.  Paralysis  of  one  upper  and  one  lower  extremity 
is  not  uncommon,  as  is  also  a  general  paralysis  of  all  four  limbs,  with 
some  involvement  of  the  neck  and  trunk.  Less  often  one  arm  is  attacked, 
the  lower  extremities  being  spared;  and  still  less  often  both  arms  only. 
When  the  extremities  of  both  sides  of  the  body  are  involved,  one  side  is 
almost  always  more  severely  affected  than  the  other. 

As  already  stated,  there  may  be  a  combination  of  some  of  the  different 
forms  of  the  disease.  Thus  it  occasionally  happens  that  paralysis 
of  some  of  the  extremities  occurs  in  combination  with  a  facial  palsy. 
Some  idea  of  the  frequency  of  paralysis  in  different  parts  of  the  body 
may  be  obtained  from  the  following  statistics  condensed  from  figures 
given  by  Lovett  and  Richardson,^  based  on  1158  cases: 

T.\BLE  73. — Regions  Paralyzed  in  Poliomyelitis — America 

Per  cent. 

One  leg  only 27.97 

Both  legs 23.48 

Both  legs  and  arms 11.13 

One  leg  and  one  arm,  same  side 9 .  49 

One  arm  only 7 .  25 

Both  arms  only 1 .  98 

Face 6.38 

Abdomen 5 .  78 

Neck 0.94 

Respiration 2.67 

Deglutition 0 .  60 

European  statistics  may  be  compared  by  consulting  the  analysis 
given  by  Wickman,^  but  reduced  to  percentages,  of  his  868  cases  with 
paralysis. 

Table  74. — -Regions  Paralyzed  in  Poliomyelitis — Swede^j 

Per  cent. 

One  or  both  legs 40 .  67 

One  or  both  arms 8 .  64 

Combined  paralysis  of  arms  and  logs.             17.51 

Legs  and  trunk • 9.79 

Arms  and  trunk 1.15 

Trunk  alone 1 .  04 

"  Whole  body  ".. .  2.65 

Ascending  paralysis .  3 .  69 

Descending  paraly.sis .  .  1 .  50 

Combined  spinal  and  cerebral  nerves 3 .  92 

Cerebral  nerves  alone 2 .  65 

Localization  not  defined 6.91 

The  constitutional  symptoms  of  the  stage  of  invasion  persist  during 
the  first  3  or  4  days  of  the  acute  paralytic  stage,  but  last  very  seldom 
more  than  6  or  7  days  in  all  from  the  onset,  and  often  a  decidedly  shorter 
time.  Pain,  a  frequent  symptom,  may,  however,  continue  several 
weeks.     There    is    no  anesthesia.     Generally  after   cessation  of  acute 

1  Infantile  Paralysis  in  Massachusetts  during  1910,  92, 
-  Die  acute  Poliomyelitis,  1911,  44. 


ACUTE  POLIOMYELITIS 


527 


constitutional  symptoms  there  is  no  addition  to  the  paralysis.  To 
this  there  are  sometimes  exceptions  seen,  and  paralysis  continues  to 
increase  for  a  few  days  longer.  The  condition  of  the  spinal  fluid  in 
this  stage  has  already  been  considered  (p.  525). 

Stationary  Stage. — This  follows  the  cessation  of  acute  symptoms 
and  lasts  from  1  to  6  weeks.  No  change  takes  place  in  the  paralytic 
condition  except  that  atrophy  rapidly  develops;  and  no  other  symptoms 
of  any  sort  are  present,  except  in  some  cases  a  decided  persistence  of 
a  degree  of  pain  and  of  hyperesthesia.  During  the  stationary  period 
the  paralysis  seems  often  very  extensive  and  complete.  Paralysis  of 
the  muscles  of  the  trunk  is  not  in- 
frequent; even  those  of  the  neck  and 
abdomen  and  the  muscles  of  respiration 
being  more  or  less  involved.  In  such 
cases  of  extensive  paralysis  the  child 
lies  helpless  in  bed,  and  if  lifted  to  a 
sitting  position  is  unable  to  support  the 
bodj?^  or  to  hold  the  head  erect.  It  is 
impossible  at  this  period  to  predict 
how  complete  the  paralysis  will  remain. 

Stage  of  Retrogression. — At  the  end 
of  the  stationary  period  improvement 
begins.  The  greater  part  of  this  will 
occur  in  the  first  6  months,  less  in  the 
next  half  year,  but  some  degree  takes 
place  even  up  to  the  end  of  2  years. 
Meanwhile  atrophy  becomes  still  more 
distinct  in  the  muscular  tissue  which 
is  not  undergoing  improvement,  and 
by  2  months  is  very  decided.  The 
affected  limb  is  then  usually  much 
smaller  than  normal  in  circumference, 
and  peculiarly  soft  and  flabby.  There 
is  no  tactile  anesthesia  or  analgesia. 
The  paralysis  is  flaccid  in  nature  (Fig. 
165),  there  being  diminished  muscle- 
tonus  and  diminution  or  absence  of 
tendon  reflexes. 

Cases  which  at  first  seemed  severely    complete  paralysis  in  the  lower  ex- 
paralyzed  improve  usuallv  greatly  during    tr<^"iitf «.    with  /"ot-drop.    From  a 

rV-  •      1       r        J,  *•  tS      1     1  1         patient    in    the    (  luldrcn  s    Hospital. 

this  period  oi  retrogression.     Probably    Philadelphia, 
in  these  cases  the  muscular  paralysis  is 

dependent  chieflj^  upon  the  pressure  of  the  edema  and  of  the  colhilar 
infiltration.  Those  muscle-fibres  connected  with  ganglion  cells  wiiich 
have  been  destroyed  can  never  regain  their  power.  It  is  not  possible 
early  to  determine  how  much  of  such  actual  destruction  has  taken  place. 
Chronic  Atrophic  Stage. — In  the  final  condition  the  growth  of  the 
aff"ccted  limb  is  much  interfered  with,  the  limb  being  both  smaller 
in  circumference  and  shorter  than  normal,  the  muscles  greatly  wasted 
and  the  ligaments  much  relaxed,  allowing  deforniilies  to  result  t'lum 
yielding  of  the  articulations.  The  skin  is  cold,  blue,  and  marbled,  and 
the  patient  sufl"crs  from  a  sensation  of  coldness  in  the  paralyzed  parts. 
Contractions  commence  even  during  the  stage  of  retrogression,  and  in 
the  chronic  stage  are  well  developed,  the  stronger  muscles  overcoming 


Fig.      165. — Paralysis     in      Polio- 


MYKLITIS. 


Recent    case    in    pirl    of    (i    years. 


528 


THE  DISEASES  OF  CHILDREN 


the  weaker  paralyzed  ones.  Talipes  and  lateral  spinal  curvature  are 
among  the  commoner  of  the  deformities.  The  parts  of  the  body  oftenest 
showing  residual  paralysis  are  one  or  both  lower  extremities,  one  limb  being 
always  worse  than  the  other.  Next  most  frequent  is  one  upper,  or  one 
upper  and  one  lower  extremity.  Thus  the  muscles  oftenest  and  most 
severely  invaded  in  the  primary  paralysis  are  those  which  are  left  para- 
lyzed finalh'. 


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Fig.   166.  Fig.   167. 

Fig.  166.- — Poliomyelitis.  Progressive  Form. 
E  J.,  male,  aged  10  years.  Aug.  27,  fever,  malaise,  headache;  Aug.  28,  slight  restless- 
ness; Aug.  29,  nervous,  head-sweating,  neck  rigid,  fever.  Weakness  of  left  leg  in  morning, 
entirely  paralyzed  by  noon.  Right  leg  weak  at  4  p.  m.,  totally  paralyzed  at  8  p.  m.  Upper 
extremities  and  shoulder  muscles  paralyzed  by  evening;  Aug.  30,  paralysis  of  muscles].of 
deglutition  and  respiration.  Cerebrospinal  fluid  under  increased  pressure,  94  cells  to 
the  c.mm.     Child  conscious  until  2  p.  m.,  died  at  5  p.  m.     Courtesy  of  Dr.  M.  Ostheimer. 

Fig.  167. — Poliomyelitis,  Bulbar  Form. 
Charles  J.,  aged  4  years.  Aug.  21.  Tonsillitis  on  the  17th.  Fever  disappeared  but 
returned  today,  with  nervousness,  dullness,  vomiting,  loss  of  appetite,  dry  tongue,  con- 
stipation; Aug.  22,  nearly  comato.se,  muscular  twitching,  tympanites,  high  fever,  in- 
creased knee-jerks,  pain  in  arms  and  legs,  slight  paralysis  of  face.  Later. — Little  change 
for  5  days,  except  increasing  paralysis  of  the  right  side  of  the  face,  and  apparently  some 
difficulty  in  swallowing.  Then  gradual  improvement  in  all  symptoms,  with  loss  of  knee- 
jerks.     Very  decided  paralysis  of  the  face  remained,  with  slight  weakness  in  the  right  leg. 

Electrical  Reactions. — The  importance  of  this  matter  makes  it 
advisable  to  consider  together  the  conditions  observed  in  the  different 
stages.  By  the  beginning  of  the  2d  week  of  the  attack  both  faradic 
and  galvanic  contractility  are  lost  in  the  severely  paralyzed  muscles. 
Very  soon,  oftenest  in  the  course  of  the  2d  week,  there  is  a  reappearance 
and  then  an  increase  in  the  galvanic  response,  with  the  presence  of  the 
reaction  of  degeneration.  The  galvanic  contractility  then  diminishes, 
but  still  with  the  degenerative  reaction  which  may  last  for  some  months. 


ACUTE  POLIOMYELITIS 


529 


Finally,  perhaps  after  2  or  3  years,  all  electrical  contractility  of  any 
sort  disappears  in  the  permanently  paralyzed  muscles.  In  those  which 
recover,  faradic  contractility  slowly  reappears  and  the  galvanic  returns  to 
a  normal  condition.  In  muscles  but  little  affected  faradic  contractility 
may  never  be  more  than  merely  diminished. 


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2.  Progressive  Form  {Landry's  Paralysis  Type). — This  form,  not 
a  common  one,  is  characterized  by  the  rapid  extension  of  the  lesions 
until  the  medulla  is  involved.  It  was  seen  in  45  (4.39  per  cent.)  of 
Wickman's^  1025  cases.  The  paralysis  generally  begins  in  the  lower 
extremities  and  ascends  to  the  arms,  involving  the  muscles  of  the  trunk 

^  Die  acute  Poliomyelitis,  1911,  53. 
34 


530 


THE  DISEASES  OF  CHILDREN 


including  those  of  respiration,  and  sometimes  the  diaphragm  and  even 
the  muscles  of  deglutition.  The  course  is  rapid,  death  following  in  a 
few  days  (Fig.  166).  Sometimes  the  arms  are  attacked  first,  and  the 
extension  is  then  of  the  descending  type.  It  is  probable  that  the  majority 
of  the  cases  which  have  been  described  as  Landry's  paralysis  should  be 
grouped  here.     (See  Landry's  Paralysis,  Vol.  II,  p.  382.) 

3.  The  Bulbar  or  Pontine  Form. — Formerly  this  condition  was 
described  as  a  distinct  disease  under  the  title  of  ''Polioencephalitis 
superior  or  inferior,"  according  to   which  of  the  nuclei  were  involved. 

The  lesions  may  be  limited  to  the  nuclei  of 
the  cranial  nerves,  or  may  be  combined  with 
spinal  lesions  (Figs.  167,  168).  The  facial 
nucleus  is  the  one  oftenest  affected,  and 
the  abducent  and  the  hypoglossal  fre- 
quently; but  any  of  the  cranial  nerve- 
nuclei  may  be  involved  with  the  pro- 
duction of  the  corresponding  symptoms, 
among  them  central  paralysis  of  respira- 
tion, paralysis  of  deglutition,  and  disturb- 
ances of  the  heart's  action.  Although  the 
bulbar  paralyses  usually  recover  com- 
pletely, a  transitory  paralysis  of  some 
muscles  of  the  limbs  may  sometimes  be 
combined  with  a  permanent  facial  palsy, 
and  the  diagnosis  may  later  be  difficult 
if  the  early  history  of  the  attack  is  not 
known.  The  bulbar  form  is  not  infre- 
quently seen,  6.45  per  cent,  of  Wickman's^ 
868  cases  belonging  here. 

4.  Acute  Encephalitic  Form. — The 
variety  bearing  this  name  was  described 
by  Striimpell^  as  "acute  encephalitis  or 
poliencephalitis  of  children,"  and  its  close 
relationship  to,  or  identity  with,  poliomy- 
elitis suggested.  It  is  now  generally  rec- 
ognized as  a  variety  of  poliomyelitis.  It 
is  one  of  the  most  unusual  types  of  the 
disease.  In  it  the  grey  matter  of  the  cortex 
is  probablj^  involved.  The  early  symp- 
toms show  great  variation  but  suggest  those  of  meningitis.  The  disease 
may  begin  with  convulsions,  which  may  be  unilateral,  somnolence  de- 
velops, and  a  paralysis  appears  with  increase  of  tendon-reflexes.  Later  the 
paralysis  is  found  to  be  of  a  spastic  type  and  to  some  extent  of  hemiplegic 
distribution,  showing  its  cerebral  origin.  This  can  be  combined  with 
flaccid  paralysis  located  in  other  regions,  and  due  to  coincident  involve- 
ment of  the  lower  segment  of  the  cerebrospinal  system  (Fig.  169). 

5.  The  Ataxic  Form. — This  is  likewise  an  unusual  form,  seen  in  only 
0.43  per  cent,  of  Lovett  and  Richardson's^  1158  cases.  In  it  ataxia  is 
the  chief  symptom,  oftenest  of  the  lower  extremities,  or  being  more  exten- 
sive; and  this  either  occurs  alone  or  is  combined  with  cerebral  symptoms, 
especially  paralysis  of  the  cranial  nerves,  and  sometimes  with  a  moderate 

^  Die  acute  Poliomyelitis,  1911,  44. 

2  Jahrbuch  fur  Kinderheilkunde,  1885,  XXII,  173. 

2  Loc.  cit 


Fig.  169. — Combined  Lesions  in 
Poliomyelitis. 
Infant  of  3  months  in  the 
Children's  Hospital  of  Philadel- 
phia. Facial  palsy,  flaccid  par- 
alysis of  the  legs,  spastic  paralysis 
of  the  arms. 


ACUTE  POLIOMYELITIS 


531 


degree  of  spinal  paralysis  as  well.  Cases  of  acute  cerebellar  ataxia  are 
probably  in  most  instances  to  be  classed  here.  (See  Cerebellar  Ataxia, 
Vol.  II,  p.  383.) 

6.  The  Polyneuritic  Form. — The  disease  in  this  form  simulates 
multiple  neuritis  so  closely  that  its  existence  has  been  much  disputed. 
It  certainly  is  a  rare  variety.  It  is  characterized  by  the  severe  pain  and 
tenderness  in  the  nerve-trunks  and  muscles.     The  pain  may  be  present 


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170. 
Fig.  170. — Poliomyelitis,  Meningitic  Type. 

Boy,  aged  8  years.  June  11,  attacks  of  headache  and  convulsions;  June  12,  somnolence, 
retraction  of  head,  opisthotonos,  pain  on  movement,  rigidity  of  limbs,  at  times  tremor, 
patellar  reflexes  appeared  to  be  increased.  Later. — Condition  little  changed  for  4-5  days, 
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paralysis  at  any  time.  (Wickmann,  Beilrdge  z.  Kentn.  d.  Heine- Medinsch.  Krankh,  1907. 
15;  100.) 

Fig.  171. — Poliomyelitis,  Aboktive  Type. 

Walter  B.,  aged  5  years.  Illness  began  Sept.  22,  during  an  epidemic,  with  fever,  stiff- 
ness in  feet,  slight  headache,  constipation,  and  Io.ss  of  appetite;  Sept.  23,  examination 
shows  child  drowsy,  feverish,  does  not  answer  questions,  throat  red,  slight  tache.  plantar 
reflexes  slightly  exaggerated,  other  reflexes  normal.  Spinal  fluid  under  increased  pressure, 
clear,  cell-count  30,  with  22  polymorphonuclear  cells,  no  organisms;  Sept.  24,  some)jerk- 
ing  of  legs  and  arms;  Oct.  2,  child  convalescing,  but  difficulty  in  straightening  legs  when 
sitting  up,  Kernig's  sign  present  both  sides,  knee-jerks  and  plantar  reflexes  slightly 
exaggerated;  Oct.  4,  excellent  general  condition.     No  suggestion  of  paralysis. 

in  the  joints  as  well.  The  paralysis  may  sometimes  be  slight  or  transi- 
tory, or  even  overlooked,  and  the  limbs  held  rigidly  to  guard  against 
pain  on  movement.  In  other  cases  the  paralysis  is  extensive.  Dis- 
turbances of  sensibility  are  usually  absent. 

7.  The  Meningitic  Form  (Fig.  170). — In  this  variety,  not  un- 
common in  epidemics,  the  very  marked  symptoms  indicating  implica- 
tion of  the  meninges  overshadow  all  other  manifestations.     There  are 


632 


THE  DISEASES  OF  CHILDREN 


vomiting,  headache,  pain  and  rigidity  in  the  neck  and  back  even  with 
moderate  opisthotonos,  convulsions,  dehrium  and  coma.  Not  all  these 
are  present  in  any  one  case,  and  combinations  of  any  sort  are  possible. 
A  diagosis  can  be  made  only  if  paralysis  develops.  The  cases  are  often 
severe  and  death  may  occur  in  a  few  days. 

8.  The  Abortive  Form  (Fig.  171). — The  frequency  and  even  the  possi- 
bility of  such  cases  have  come  into  prominence  only  in  recent  years.  Their 
existence  has  been  proven  experimentally  by  Flexner  and  Clark, ^  and 
especially  by  Anderson  and  Frost^  through  the  discovery  of  immunizing 
bodies  in  the  serum  of  patients  who  had  suffered  from  this  form  of  the 
disease,  and  by  the  production  of  the  disease  in  animals  by  the  inoculation 


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Fig.   172. — Poliomyelitis,  Abortive  (Rudimentary)  Form. 
E.  B.,  girl,  aged  4  years.     Onset  with  nausea,  slight  sore  throat,  headache  and  fever. 
Spinal  fluid  on  5th  day  showed  no  increase  of  pressure,  leucocytes  36  to  c.  mm.,  with  63 
per  cent,  lymphocytes.     Apparently  convalescent  on  6th  day.     On  17th  day  slight  weak- 
ness in  both  legs  which  disappeared  by  21st  day.     Courtesy  of  Dr.  M.  Ostheimer. 

with  the  virus  from  abortive  cases.  There  is  abundant  clinical  evidence 
also,  as  seen  in  families  where  some  cases  are  of  the  typical  form,  and 
others  have  only  initial  symptoms  without  any  subsequent  paralysis. 
The  spinal  fluid,  too,  exhibits  the  characteristic  changes.  The  attack 
begins  abruptly  with  the  prodromal  manifestations  already  described. 
There  is  fever  of  varying  type,  usually  constipation,  prostration,  severe 
headache,  and  often  vomiting.  Frequently  hyperesthesia  is  present 
with  stiffness  of  the  neck  and  pain  here  and  in  the  back.  Sore  throat 
may  be  present,  or  rhinitis  and  conjunctivitis.  In  some  instances 
there  is  a  muscular  weakness  or  a  certain  unsteadiness  in  walking.  The 
character  of  the  symptoms  varies  decidedly,  as  in  the  initial  stage  of  the 

^Loc.  cit.,  585. 

2  Journ.  Amer.  Med.  Assoc,  1911,  LVI,  663. 


ACUTE  POLIOMYELITIS  ,  533 

ordinary  form.  Sometimes  gastrointestinal  manifestations  prevail; 
sometimes  respiratory;  sometimes  nervous.  After  continuing  2  or  3 
days,  there  is  rapid  recovery.  To  this  class  of  abortive  cases  might 
be  added  what  E,  Miiller^  has  denominated  the  "rudimentary  form'' 
(Fig.  172),  in  which  a  very  slight  transitory  paralysis  is  seen  with  tempo- 
rary loss  of  the  patellar  reflexes.  This  is  in  contradistinction  to  cases 
without  any  evidences  whatever  of  paralysis,  which  he  calls  the  "larval 
form." 

Abortive  cases  are  frequent  in  epidemics  and  doubtless  often  over- 
looked. Miiller  estimated  that  one-half  of  the  cases  of  poliomyelitis  are 
of  this  type,  and  of  Wickman's^  1025  cases  157;  i.e.  15.32  per  cent.,  were 
of  the  abortive  type.  In  the  second  great  Swedish  epidemic  the  abortive 
cases  in  some  localities  greatly  exceeded  those  with  paralysis  (Wernstedt),^ 
and  the  same  is  probably  true  of  the  1916  epidemic  in  the  United  States. 

Relapse. — Occasionally  after  the  development  of  paralytic  symptoms 
of  moderate  degree,  there  is  an  intermission  of  6  or  7  days,  after  which 
there  is  renewed  extension  of  paralysis  with  reappearance  of  other  symp- 
toms. In  some  cases  this  is  probably  only  a  later  manifestation  of  the 
initial  lesion;  but  in  others  there  appears  to  be  a  true  relapse  occurring, 
it  may  be  weeks  after  the  primary  attack.  Leegaard*  reports  a  case 
probably  of  this  nature  in  which  there  was  an  interval  of  nearly  3  weeks. 

Recu  rrence. — A  patient  who  has  once  suffered  from  the  disease  appears 
to  be  immune.  Experimental  work  with  monkeys  likewise  shows  that  the 
prompt  injection  of  the  blood  of  other  monkeys  or  of  human  beings,  who 
have  had  the  disease,  will  sometimes  prevent  or  delay  the  development 
of  paralysis  after  inoculation.  The  immunizing  principle  has  been  found 
in  the  blood  of  individuals  several  years  after  the  attack  of  the  disease 
(Flexner  and  Clark). ^  There  are,  however,  occasional  exceptions  to  this 
rule  of  lasting  immunity,  and  second  attacks  have  been  reported,  as  by 
Sanz®  and  by  Lucas  and  Osgood.^ 

Prognosis. — Formerly  poliomyelitis  was  considered  a  disease  not  at 
all  dangerous  to  hfe,  and  only  to  be  feared  on  account  of  the  hfelong 
crippling  which  it  left.  Experience  in  more  recent  years  shows  that  under 
epidemic  influences  the  mortality  can  be  very  decided.  Thus  Krause* 
reports  a  mortality  of  15.14  per  cent,  in  436  cases;  Zappert^  10.99  per  cent. 
in  555  cases;  Lindner  and  Mally^"  over  16  per  cent,  in  96  cases;  Wickman^^ 
12.2  per  cent,  in  1025  cases  or  16.7  per  cent,  if  the  157  abortive  cases  are 
excluded;  Johannessen^^  13. 08  per  cent,  in  1407  cases;  Lecgaard^^  17.1  per 
cent,  in  3290  cases.  The  American  death-rate  has  been  somewhat  less. 
Lovett  and  Richardson '''  found  a  mortality  of  7.9  per  cent,  in  1216  cases 
in  Massachusetts,  when  in  approximately  2000  cases  in  New  York  City 
the  mortality  was  about  5  per  ceiit.''^     A  notable  exception  to  thecompara- 

1  Loc.  cit.,  146. 

2  Beitragc  zur  Kentniss  dor  Hcinc-Mcdinsclipn  Kranklieit,  1907,  288. 
•^  Wernstedt,  Jahrb.  f.  Kindcrli.,  l'.)12.  LXXVI,  005. 

^  Nordk.  Mag.  for  Laegevid,  HIOl,  XVI,  ;i77. 

^  Loc.  cit. 

•  El  Siglo  Med.,  1915,  LXII,  .5:30.     lief.,  Brit.  Jour.  Cliild.  Dis.,  1916,  XIII,  56. 

'  Journ.  Amor:  Mod.  As.soc,  1913,  LX,  Kill. 

«  Deut.scho  mod.  Woohonsclir.,  1909,  XXXV,  1S22. 

^  Dio  Kliiiik.   u.  l'4)idomi(il()gio  d.  acute  Kiudorlahmuiig. 
'"  Zoitsolirift  fiir  Xorvonhoilkimdc,  1910.  XXXVI 11.  :{()2. 
"  Boitriigo  7AU-  Koutniss  dor  IIoiMo-Modiiisolien  Kranklioit.,  1907.286. 
'2  Jahrb.  f.  Kindorli.,  1912.  LXXVI,  603. 
»-^  Deut.  Zeit.  f.  Xorvonhoilk.,  1914-15,  LIII,  222. 
*•'  Loc.  cil.,  78. 
'*  Report  of  New  York  Collective  Investigation  Committee,  1910,  24. 


534  THE  DISEASES  OF  CHILDREN 

tively  low  mortality-rate  was  seen  in  the  epidemic  in  New  York  State 
in  1916.  In  this  there  were  approximately  13,000  cases"  with  a  mortality 
of  25  per  cent  (Nicoll).^  The  abortive  cases,  of  course,  give  an  entirely 
favorable  prognosis.  Cases  of  the  polj^neuritic  type  may  have  paralysis 
persist,  or  there  may  be  complete  recovery.  The  ataxic  symptoms  of  the 
form  of  the  disease  bearing  this  name  are  never  more  than  a  temporary 
matter.  The  fatal  cases  are  seen  especially  in  the  progressive  form, 
which  nearly  always  ends  in  death,  and  in  the  acute  encephalitic  and  the 
meningitic  forms,  both  of  which  are  serious  conditions.  The  occurrence 
of  complications  is  a  not  infrequent  cause  of  death.  Among  these  is  to  be 
mentioned  especially  bronchopneumonia.  In  the  fatal  cases  death  is 
liable  to  occur  in  the  first  3  to  5  days,  during  the  continuance  of  the  active 
constitutional  symptoms,  and  probably  certainly  in  the  first  2  weeks  of 
the  attack.  After  this  period  recovery  is  almost  assured  so  far  as  life 
is  concerned.  The  influence  of  the  age  of  the  patient  is  very  decided. 
Statistics  show  that  the  mortality  in  children  is  decidedl}^  less  than  later. 
Wickman^  found  a  mortality  from  0  to  2  years  of  10  per  cent,  and  from  3 
to  5  years  of  11.6  per  cent.;  gradually  increasing  until  from  30  to  32  years 
it  was  33.3  per  cent. 

The  likelihood  of  recovery  from  the  paralytic  condition  is  a  matter  of 
prognostic  importance.  The  early  paralysis  of  the  trunk  and  neck  seen  in 
the  spinal  cases  will  probably  disappear.  Not  infrequently  all  traces  of 
paralysis  everywhere  may  cease  to  exist.  Lovett  and  Richardson^  found 
that  in  16.7  per  cent,  of  150  cases  analyzed  by  them  all  evidences  of  the 
disease  had  disappeared  within  3  months.  Wickman'*  was  able  to  study 
530  cases  of  primary  paralysis  from  1  to  1^^  years  after  the  attack.  Of 
these  56  per  cent,  still  showed  paralysis  and  44  per  cent,  none  at  all.  The 
paralysis  in  cases  of  the  bulbar  type  generally  disappears  completely. 
Very  commonly,  however,  in  the  spinal  cases  some  evidence  of  paralysis 
remains  throughout  life.  This  may  vary  anywhere  from  complete  dis- 
ability to  a  slight  impairment  of  motion,  most  frequently  seen  as  a  trifling 
limp  in  walking.  The  ultimate  degree  of  disability  depends  often  upon 
the  faithfulness  with  which  treatment  has  been  carried  out.  The  muscles 
of  the  arms  and  shoulders  seem  less  liable- to  undergo  recovery  than  those 
of  the  legs.  Muscles  in  which  entire  paralysis  and  complete  loss  of 
faradic  contractility  are  present  after  the  acute  stage  is  over,  in  the  course 
of  the  2d  week,  are  liable  to  be  more  or  less  permanently  paralyzed. 
If  slight  return  of  faradic  contractility  is  found  in  the  course  of  a  few  days 
longer,  partial  recovery  will  probably  follow.  If  after  2  or  3  months  there 
is  much  wasting  and  loss  of  power  and  continued  loss  of  faradic  contrac- 
tility, little  improvement  can  be  expected.  Muscles  which  have  never 
exhibited  electrical  changes  will  probably  recover  completely  in  a  few 
weeks  or  months.  Even  in  cases  seen  for  the  first  time  in  the  chronic 
stage,  if  there  is  some  degree  of  faradic  contractility  remaining,  consider- 
able improvement  under  treatment  may  be  expected. 

Diagnosis. — -It  seems  impossible  to  recognize  poliomyelitis  with 
certainty  in  its  prodromal  stage.  Lumbar  puncture  made  just  before 
paralysis  appears  shows  a  clear  or  slightly  opalescent  fluid,  containing  an 
increase  of  mononuclear  cells,  and  a  moderate  globulin  reaction.  A 
spinal  fluid  of  this  nature  may  be  readily  distinguished  from  that  of  cere- 

1  Amer.  Jour.  Dis.  Child.,  1917,  XIV,  69. 

2  Beitrage  zur  Kentniss  der  Heine-Medinschen  Krankheit.,  1907,  288. 

3  Loc.  cit.,  70. 

*  Die  acute  Poliomyelitis,  1911,  78. 


ACUTE  POLIOMYELITIS  535 

brospinal  fever,  but  not  positively  from  tuberculous  meningitis.  In  the 
latter  the  albumin  and  globulin  are  generally  greater  in  amount,  the 
sugar  diminished  or  absent,  and  the  cells  more  numerous.  But  to  this 
there  are  so  many  exceptions  that  the  differences  are  not  trustworthy. 
Moreover,  the  symptoms  of  poliomyelitis  are  so  very  indefinite  that  it 
would  be  necessary  to  perform  lumbar  puncture  on  every  child  with 
manifestations  of  a  dubious  sort.  It  is  only  when  an  epidemic  is  pre- 
vailing that  the  beginning  of  poliomyelitis  will  be  thought  of  and  that 
lumbar  puncture  will  be  tried.  The  most  suggestive  of  the  early  mani- 
festations are  hyperesthesia,  sweating,  and  nervous  irritability.  The 
variation  of  the  complex  of  early  symptoms,  however,  makes  a  number  of 
different  diagnoses  possible  at  this  time.  Vomiting  and  constipation 
suggest  a  gastrointestinal  disorder;  severe  diarrhea,  an  intestinal  auto- 
intoxication; severe  pain  in  the  head  and  stiffness  of  the  neck  and 
convulsions,  a  cerebrospinal  fever  or  other  similar  form  of  meningitis; 
somnolence  or  coma  with  rigidity,  a  tuberculous  meningitis;  headache' 
coryza,  decided  prostration  and  rapid  pulse,  grippe.  Cerebrospinal 
fever  has  symptoms  very  similar  to  poliomyelitis  with  decided  meningitic 
symptoms.  Lumbar  puncture,  however,  shows  a  cloudj^  or  even  purulent 
fluid,  with  numerous  polymorphonuclear  cells.  The  blood,  too,  in  the 
first  disease  exhibits  uniformly  a  high  leucocj^tosis.  Fever  is  of  longer 
duration  in  cerebrospinal  fever  and  there  is  oftener  coma.  The  reflexes 
are  increased  and  a  spastic  condition  soon  develops. 

Tuberculous  meningitis  exhibits  a  spinal  fluid  very  like  that  of  polio- 
myelitis and  the  diagnosis  may  be  impossible  for  some  days.  Then, 
however,  the  failure  of  paralysis  to  appear  and  the  increase  of  the  stu- 
porous condition  point  to  the  former  malady.  The  onset  of  meningitis 
is  usually  much  more  insidious,  although  to  this  there  are  exceptions. 

When  once  paralysis  has  developed,  the  diagnosis  of  poliomyelitis  is 
usually  apparent,  although  it  often  happens  that  this  condition  is  not 
recognized  for  some  time,  the  helpless  state  being  supposed  to  be  the 
result  of  prostration.  Even  after  the  stage  of  retrogression  is  over, 
mistakes  in  diagnosis  are  still  possible.  There  is  scarcely,  however,  any 
other  form  of  paralysis  which  gives  the  picture  of  flaccidity,  atrophy,  and 
flail-like  freedom  of  movement  at  the  articulations,  unless  it  be  multiple 
neuritis.  This  disease  is  more  frequent  than  the  polyneuritic  type  of 
poliomyelitis,  the  onset  is  slower,  and  there  are  no  cerebral  symptoms.  It 
IS  generally  much  more  widespread  over  the  body  and  there  is  consider- 
ably more  pain  in  the  limbs;  yet  this  last  feature  is  not  a  safe  diagnostic 
sign.  A  diminution  of  the  touch-sense  indicates  the  presence  of  neuritis 
rather  than  poliomyelitis.  The  likeness  of  the  two  diseases  is  certainly 
very  close,  but  the  anatomical  identity  is  not  yet  proven.  A  localized 
neuritis,  oftencst  of  one  arm,  as  in  instances  of  obstetrical  paralysis, 
sometimes  causes  error  in  diagnosis.  Only  the  history  of  the  case  can 
distinguish  it.  Infantile  scurvy  may  readily  simulate  poliomyelitis 
through  the  development  of  pseudo-paralysis,  the  result  of  pain  on 
movement.  I  have  seen  the  mistake  in  diagnosis  made  in  a  number  of 
instances.  The  associated  symptoms,  the  history  of  the  case,  and  the 
prompt  reaction  to  antiscorbutic  treatment  soon  settle  the  question. 
The  pseudo-paralysis  of  severe  rickets  has  repeatedly  been  supposed  to  be 
the  result  of  poliomyelitis.  A  little  care  in  observation  will  remove  all 
doubt.  In  rickets  there  is  the  history  of  slow  onset  and  the  jiresence  of 
associated  symptoms.  There  exists  a  weakness  rather  than  a  paralysis, 
and  this  is  widespread  and  not  nioie  marked  on  one  side  than  tiie  other. 


536  THE  DISEASES  OF  CHILDREN 

Electrical  reactions  also  are  different.  The  ordinary  cerebral  paralyses 
are  not  easily  confounded.  They  are  spastic  in  character,  with  exagger- 
ated tendon  reflexes.  Only  in  the  uncommon  acute  encephalitic  form  of 
poliomyelitis  is  there  a  spastic  paralysis  present.  The  history  of  the 
attack  aids  in  the  diagnosis,  as  would  the  early  employment  of  lumbar 
puncture.  Even  the  contractions  about  the  joints  in  old  cases  of  polio- 
myelitis are  easily  recognized  not  to  be  spastic  in  character,  but  due  to 
actual  shortening  of  the  muscles.  In  instances  of  the  bulbar  form  of 
poliomyelitis,  facial  paralysis  may  readily  be  supposed  to  be  a  BelVs 
palsy,  due  to  neuritis  of  the  facial  nerve.  The  history  of  the  attack  is, 
however,  entirety  different  and  the  frequent  combination  of  some  paraly- 
sis of  the  limbs  makes  the  matter  clear. 

Treatment.  Prophylaxis. — Until  there  is  greater  knowledge  of  the 
method  by  which  the  disease  is  contracted,  little  can  be  expected  in  the 
way  of  preventive  treatment.  The  fact  that  the  virus  is  found  at  times  on 
the  nasal  mucous  membrane,  and  even  may  be  virulent  long  after  the  dis- 
ease is  over,  indicates  the  advisability  of  thorough  frequent  disinfection  of 
this  region  in  patients  suffering  with  the  disease,  in  the  hope  of  pre- 
venting its  dissemination.  This  brings  up,  too,  the  subject  of  separation 
and  quarantine.  In  spite  of  the  absence  of  positive  evidence  of  direct 
transmission,  quarantine  should  be  enforced,  especially  during  an 
epidemic  prevalence  of  the  disease.  With  a  lack  of  knowledge  of  the 
usual  period  of  infectiousness,  the  proper  duration  of  isolation  is  a  matter 
of  uncertainty.  A  quarantine  of  3  weeks  would  seem  ample,  unless 
inflammation  of  the  nose  and  throat  is  present.  How  much  longer  would 
be  necessary  to  ensure  absolute  safety  cannot,  as  yet,  be  determined. 
A  child  who  has  been  exposed  may  be  considered  safe  if  not  developing 
the  disease  in  2  weeks.  Those  who  have  come  into  contact  with  patients 
should  employ  disinfection  of  the  nose  and  throat  to  prevent  the  pos- 
sibilit}^  of  their  acting  as  carriers;  or,  still  better,  wear  a  mask  of  gauze 
or  similar  substance  over  the  mouth  and  nose.  The  discharges  from  the 
mouth  and  nose  of  the  patient  should  be  promptly  destroyed.  After 
the  roon  is  vacated,  it  should  be  thoroughly  disinfected.  It  is  also 
advisable  not  to  take  children  to  localities  where  the  disease  is  epidemic; 
or,  if  already  there,  to  forbid  their  association  with  those  who  have 
recently  had  the  affection,  or  with  those  who  are  ill  with  any  vague 
symptoms,  as  well  as  to  prevent  their  frequenting  public  conveyances 
or  public  places  of  amusement  where  many  children  are  together. 

The  ability  to  immunize  human  beings  in  times  of  epidemics  would 
be  most  desirable,  and  may  be  finally  accomplished.  It  has  sometimes 
been  done  successfully  in  monkeys  by  Flexner  and  Lewis^  and  others, 
but  as  yet  it  is  too  uncertain  for  application  to  human  medicine. 

Treatment  of  the  Attack. — During  the  initial  stage  of  the  attack 
there  is  as  yet  no  treatment  of  certain  avail  open  to  us.  In  the  case 
of  monkeys  it  has  been  shown  by  Flexner  and  Clark,  ^  that  the  administra- 
tion of  hexamethylenamine  has  delayed  the  development  of  symptoms, 
and  it  is  earnestly  to  be  hoped  that  further  investigations  along  this  line 
may  result  in  a  satisfactory  treatment.  At  least  no  harm  can  follow 
the  administration  of  this  drug  in  fairly  large,  divided  doses,  of  20  to  40 
grains  (1.3  to  2.6)  daily;  but  to  be  of  any  possible  benefit  it  must  be  given 
before  paralysis  develops. 

1  Journ.  Amer.  Med.  Assoc,  1910,  LIV,  1780. 

2  Loc.  cit.,  585. 


ACUTE  POLIOMYELITIS  537 

Based  upon  animal  experimentation  in  other  conditions,  Meltzer^ 
recommended  the  administration  of  adrenahn,  giving  0.5  c.c.  (8  m.) 
of  the  1:1000  solution  intraspinally.  This  had  been  previously  tried 
by  Clark^  in  monkeys,  with  considerable  success.  Netter^  in  1910 
used  the  injection  of  blood-serum  from  subjects  who  had  previously 
suffered  from  poliomyelitis,  and  since  then  has  emploj'ed  it  in  32  cases 
with,  he  believes,  excellent  results.  In  the  1916  epidemic  this  method 
of  treatment  was  tried  in  a  considerable  number  of  instances,  apparently 
with  good  results.  Zingher"*  used  it  in  doses  of  10  to  15  c.c.  (0.34  to  0.51 
fl.oz.)  intraspinally  every  20  to  24  hours  for  2  or  3  days.  He  reported  its 
employment  in  418  cases  and  claimed  a  beneficial  action  when  given 
in  the  preparalytic  stage.  Others  share  the  opinion  that  the  results  in 
the  preparalytic  stage  are  good,  and  still  others  have  seen  about  the 
same  proportion  of  cases  escape  paralysis  when  no  serum  was  employed. 
The  great  difficulty  in  determining  the  value  of  anj^  form  of  treatment 
in  this  disease  renders  further  observations  necessary  before  any  positive 
conclusions  can  be  drawn.  In  the  preparalytic  stage  in  experimental 
poliomyelitis  in  monkeys  the  treatment  appears  to  be  of  undoubted 
value  (Flexner  and  Amoss).^ 

Complete  rest  in  bed  is  imperative,  but  counterirritation  with  blisters 
or  similar  measures  merely  adds  to  the  discomfort,  and  there  is  no 
evidence  that  it  can  be  of  avail  at  any  stage  of  the  disease.  Remedies 
may  be  needed  to  relieve  pain,  restlessness,  or  other  nervous  S3'mptoms;to 
control  fever;  and  to  support  strength.  It  is  not  yet  time  for  electricity 
and  massage,  which  can  do  no  good  and  may  do  harm.  All  such  treat- 
ment should  be  delayed  until  the  stationary  stage  is  over  and  all  tender- 
ness has  disappeared.  This  may  not  be  for  from  3  to  6  weeks  or  longer 
after  the  onset.  The  value  of  electricity  and  massage  is  to  improve  by 
this  enforced  exercise  the  tone  and  the  power  of  the  muscles  which  have 
been  only  partially  or  temporarily  injured.  Those  muscle-fibres  presided 
over  by  absolutely  atrophic  ganglion-cells  can  never  show  any  improve- 
ment. The  faradic  current  should  be  applied  to  the  different  muscles 
which  have  been  paralyzed,  continuing  the  entire  treatment  for  from  10 
to  20  minutes,  once  or  twice  a  day.  If  there  is  no  response  to  faradism, 
galvanism  may  be  tried.  Only  such  strength  of  current  of  either  sort 
should  be  used  as  will  produce  moderate  contractions  without  pain. 
Massage  and  passive  movements  can  be  commenced  as  soon  as  the  acute 
stage  is  over  and  all  hyperesthesia  and  pain  have  disappeared.  It  is  very 
important  to  combine  with  the  passive  exercise  the  encouraging  of  the 
patient  to  make  voluntary  active  movements,  no  matter  how  imperfectly 
these  are  made  at  first.  More  can  be  expected  from  this  than  from  any 
other  plan  of  treatment,  and  if  persevered  with  for  months  or  even  for 
years  remarkal)le  improveiueiit  will  often  follow  in  cases  which  at  first 
appeared  most  discouraging.  Confinement  to  bed  should  continue 
for  2  or  3  months  except  in  the  mild  cases,  when  2  or  3  weeks  may  be  suffi- 
cient. As  a  result  of  the  study  of  a  large  number  of  cases — 1830— 
Lovett^  emphasizes  the  risk  attending  the  permitting  of  any  weight- 

>  Med.  Rec,  1916,  XC,  171. 

2  Journ.  AnuT.  Med.  Assoc.  \\)V2,  I.IX,  307. 

»  Arch,  de  iik'-iI.  dcs  ciif.,  191(1.  XIX,  1. 

*  Arc-h.  of  Pnliat..  HU(i,  XXXIII.  S72. 
"  Journ.  Expcr.  Med.,  1917,  XX\'.  499. 

•  Jour.  Amcr.  xMed.  Assoc,  1917,  LXIX,  168. 


538  THE  DISEASES  OF  CHILDREN 

bearing  exercise  for  a  long  period  after  the  attack,  and  shows  that  there  is 
danger  of  increasing  the  degree  of  residual  paralysis  already  present. 

Mechanical  Treatment. — It  is  important  to  prevent  deformity  by  the 
employment  as  early  as  necessary  of  mechanical  apparatus.  Even 
during  the  early  part  of  the  stage  of  retrogression  one  must  guard  against 
beginning  deformity.  Sand-bags  at  the  soles  of  the  feet  or  the  wearing 
of  a  shoe  with  elastic  extending  from  the  toe  to  the  hip  will  aid  in  pre- 
venting the  contraction  of  the  tendo  achillis,  which  is  so  likely  to  occur. 
A  proper  position  in  bed  is  necessary,  too,  in  many  cases  to  avoid  the 
production  of  lateral  curvature.  While  the  use  of  braces  is  to  be 
deprecated  on  the  ground  that  it  adds  to  the  weight  to  be  moved  and 
removes  the  necessity  for  the  paralyzed  muscle  to  do  its  work  com- 
pletely; yet,  on  the  other  hand,  it  is  still  worse  to  allow  deformities 
of  any  part  to  develop.  The  need  for  their  employment  must  be  de- 
termined for  the  individual  case.  Sole  dependence  upon  crutches  is 
harmful,  as  it  permits  the  muscles  to  remain  in  an  entirely  unused  con- 
dition. Tenotomies  will  be  required  less  frequently  if  measures  are  early 
undertaken  to  prevent  contractions  forming.  In  some  cases  tendon- 
transplantation  may  be  performed  with  benefit.  This,  as  a  rule,  is 
best  deferred  for  at  least  2  years.  In  other  cases  artificial  anchylosis 
may  give  necessary  rigidity  to  an  otherwise  useless  joint.  The  great 
principle  of  treatment  in  the  chronic  paralytic  stage  is  never  to  abandon 
it,  since  slow  improvement  may  finally  come,  and  aid  may  be  given  in 
some  way  in  cases  at  first  most  unpromising. 


CHAPTER  XIX 
TUBERCULOSIS 


Tuberculosis  affects  many  different  parts  of  the  body,  the  local 
symptoms  usually  greatly  preponderating  over  the  general  ones,  and 
producing  clinical  pictures  essentially  different  from  each  other.  On 
this  account,  and  for  the  sake  of  greater  convenience  of  study,  some,  at 
least,  of  the  special  forms  of  tuberculosis  will  be  discussed  more  in  detail 
in  different  sections.  In  the  present  chapter  tuberculosis  as  a  whole 
will  be  considered,  especially  as  it  affects  children,  avoiding  repetition 
of  the  subject-matter  of  other  chapters  as  far  as  possible. 

Etiology.  Frequency. — As  far  back  as  the  history  of  medicine  extends 
tuberculosis  has  existed  as  one  of  the  most  frequent  of  diseases.  It  affects 
many  different  varieties  of  animals,  although  to  unequal  degrees;  being 
most  prevalent  in  man,  monkeys,  cattle  and  swine,  as  well  as  in 
poultry,  although  in  the  last  it  is  a  decidedly  different  disorder.  It  is 
rare  in  sheep,  goats,  horses,  dogs  and  cats.  Guinea-pigs  and  rabbits  are 
very  susceptible  if  inoculated.  The  actual  frequency  of  tuberculous  in- 
fection, apart  from  the  occurrence  of  lesions  found  at  autopsy,  is 
difficult  to  determine.  Not  all  cases  which  show  post-mortem  lesions 
have  died  of  this  disease.  In  many  it  is  only  a  contributory  or  an 
accidental  matter.     On  the  other  hand,  tuberculous  infection  exists  in 


TUBERCULOSIS  539 

many  cases  which  do  not  come  to  autopsy.  Of  4388  children  in  the 
schools  of  Christiania,  as  reported  by  Frohlich/  2900  were  examined 
clinically  and  by  the  cutaneous  tubercuhn  reaction.  The  former  re- 
vealed evidences  of  tuberculosis  in  61.5  per  cent.,  and  the  latter  in  83.8 
per  cent.  The  influence  of  the  age  of  the  subject  upon  the  frequency 
of  the  disease  will  be  considered  later  (p.  540). 

Predisposing  Causes. — Much  discussed  in  this  connection  is  the 
influence  of  heredity.  While  direct  inheritance  of  the  germ  is  rare,  that 
of  the  disposition  of  the  tissues  to  become  tuberculous  is  very  common. 
Any  debilitated  condition  of  the  parents  increases  the  susceptibility 
in  the  offspring,  but  the  existence  of  parental  tuberculosis  is  by  far  the 
most  powerful  factor.  The  development  of  the  disease  by  association 
with  tuberculous  parents  and  not  on  account  of  an  inherited  tendency  is 
to  be  carefully  excluded  in  drawing  conclusions.  Race  exerts  some 
etiological  influence,  but  the  effects  attributed  to  it  depend  upon  other 
associated  conditions.  The  Indians,  Irish  and  Negroes  appear  especially 
predisposed  in  the  United  States.  Climate,  locality  and  altitude  are 
prominent  factors.  With  some  exceptions  damp  regions  predispose,  and 
drj^,  elevated  localities  are  unfavorable  to  the  development  of  the  disease. 
The  frequency  of  tuberculosis  in  children  on  the  continent  of  Europe 
would  appear  from  statistics  to  be  much  greater  than  in  the  United  States, 
and  in  certain  cities  the  number  of  instances  of  infection  developing  in 
early  life  seems  to  be  particularly  high.  Unhygienic  conditions  in  general 
are  of  great  importance.  The  crowding  of  children  in  dirty  buildings, 
the  lack  of  fresh  air  and  sunlight,  insufficient  nourishment,  and  the  like, 
are  active  causes.  Previously  impaired  health  also  predisposes,  espe- 
cially derangements  of  the  respiratory  mucous  membrane,  and,  to  a 
less  extent,  those  of  the  alimentary  tract.  Many  other  diseases  pre- 
dispose, particularly  to  be  mentioned  here  being  measles,  pertussis, 
grippe,  repeated  attacks  of  bronchitis,  and  the  existence  of  hypertrophied 
tonsils  and  of  adenoid  growths.  These  various  agents  may  act  either 
by  rendering  the  subject  liable  to  the  entrance  and  development  of  the 
germs,  or  by  decreasing  the  local  or  general  resistance  of  the  organism 
and  thus  allowing  an  infection  already  present  in  the  bodj^  in  a  quiescent 
condition  to  assume  an  active  form. 

Age  exerts  a  very  positive  influence.  Congenital  tul)orculosis  is 
occasionally  seen,  as  was  proven  by  Schmorl  and  Birch-Hirschfcld- and 
others,  and  a  considerable  number  of  cases  have  been  reported  (Pehu  and 
Chalier).^  The  occurrence  is  very  possibly  more  common  than  generally 
supposed.  The  subject  has  been  reviewed  by  Weber-*  and  by  Grulee  and 
Harmes.^  Tuberculosis  is,  however,  exceptional  in  the  first  3  months  of 
life,  but  increases  rapidly  in  fnniuency  of  occurrence  after  this  period. 
Cornet*  gives  the  following  figures  based  on  1542  autopsies  on  children 
under  5  years  of  age : 

1  Norsk.  Mag.  f.  Lapgcvidnisk.,  1914,  LXXV,  1:^7.     Kef.  Moniits.srhr.  f.  Kinderh. 
Ref.,  191.'-),  XIV,  :i79. 

■'  Bc'itriiKO  z.  patli.  .\nat.  u.  z.  allg.  Patli.,  1891,  IX,  429. 
'  Arch.  (U>  mc'd.  d(«s  cnf.,  19()S,  XI,  1. 

*  Brit.  Jour.  Child.  Dis.,  191(),  XIII,  321;  359. 

*  Amer.  Jour.  Dis.  Chihl.,  1915,  IX,  322. 

*  Nothnagel's  Eiu-ycl.  Pract.  Med.,  Anier.  Ed.,  Tubc'nulo.sis.  351. 


540  THE  DISEASES  OF  CHILDREN 

Table  74. — Incidence   of  Ttjberculosis  as  Derived  from  Autopsies 


Tuberculous 


Percentage 


Birth  to  2  mos. .  . 

2  to  3  mos 

3  to  6  mos 

6  to  9  mos 

9  to  12  mos 

Total  under  1  yr. 

1  to  2  yrs 

2  to  3  yrs 

3  to  4  yrs 

4  to  5  yrs 

Total 


0 

2 
8 
15 
18 
43 
83 
56 
51 
30 
263 


0 

6.06 
10.53 
17.05 
27.69 

5.75 
26.69 
29.63 
31.86 
22.39 
17.5 


There  exists,  however,  considerable  variation  in  many  of  the  pubHshed 
statistics,  as  may  be  seen  in  the  following  selected  examples:  In 
752  autopsies  in  children  reported  by  Feldmann^  tuberculosis  was  present 
in  19.6  per  cent. ; — under  3  months,  6.3  per  cent,  of  all  autopsies  at 
this  age;  3  to  6  months,  22.8  per  cent.;  7  to  9  months,  29.1  per  cent.; 
IQ  to  12  months,  22.4  per  cent.;  1  to  2  years,  43.1  per  cent.;  over  2  years, 
71.1  per  cent.  Schlossmann^  gives  6.8  per  cent,  tuberculous  in  532 
autopsies  in  infants  under  1  year.  According  to  Hamburger^  of  848 
autopsies  in  children  in  Vienna,  39.53  per  cent,  showed  tuberculosis. 
In  the  first  3  months  it  was  present  in  4  per  cent.;  4  to  6  months,  18  per 
cent.;  7  to  12  months,  23  per  cent.;  in  the  2d  year,  40  per  cent.;  3  to 
4  years,  60  per  cent. ;  5  to  6  years,  56  per  cent. ;  7  to  10  years,  63  per  cent. ; 
11  to  14  years,  70  per  cent.  The  percentages  in  the  records  of  the 
Children's  Hospital  of  Philadelphia  (Hand)^  are  also  high;  115  of  332 
autopsies,  or  34.6  per  cent.,  revealing  tuberculous  lesions,  }i  of  these 
cases  being  in  subjects  under  2  years  of  age.  Harbitz^  for  Norway  found 
tuberculous  lesions  in  40  per  cent,  of  484  autopsies  in  children  from  1  to 
15  years  of  age.  The  Paris  mortality  is  shown  by  the  statistics  of  Comby^ 
upon  1675  autposies  with  638  (38  per  cent.)  tuberculous.  The  division 
according  to  age  was:  Of  autopsies  under  3  months,  tuberculous  1.82 
per  cent.;  3  to  6  months,  18.18  per  cent.;  6  to  12  months,  26.25  per  cent.; 
1  to  2  years,  40.72  per  cent.;  2  to  5  years,  60  per  cent.;  5  to  10  years, 
67.15  per  cent.;  10  to  15  years,  71.23  per  cent. 

The  figures  as  given  represent,  however,  only  the  finding  of  tuberculous 
lesions  at  autopsy.  They  do  not  indicate  that  the  death  was  due  to  this 
disease,  nor  do  they  show  how  often  children  of  different  ages,  who  do 
not  come  to  autopsy,  are  subjects  of  tuberculous  infection.  In  fact, 
the  older  the  child,  the  oftener  is  the  tuberculosis  lesion  a  latent  or  healed 
process.  The  question  of  the  frequency  of  tuberculosis  at  different 
periods  as  shown  by  the  tuberculin-test  (see  p.  560)  has  been  carefully 
studied  in  many  quarters.  The  figures  obtained  vary  somewhat  with 
the  locality,  as  may  be  seen  in  the  following  table : 

1  Budapest!  orvosi  ujsay,  1906.     Ref.,  Jahrb.  f.  Kinderh.,  1906,  LXIV,  763. 

2  Beitrage  z.  Klin.  d.  Tuberc,  1906,  VI,  229. 

3  Wien.  klin.  Wochenschr.,  1907,  XX,  1668. 
*  Arch,  of  Pediat.,  1903,  XX,  247. 

5  Xorsk.  Mag.  f.  Laegevidensk.,  1913,  1.  Ref.  Monatsschr.  f.  Kinderh.,  Referat., 
1914,  XIII,  429. 

«  XYLL  Intern.  Cong,  of  Med.,  1913,  Sect.  X,  38. 


TUBERCULOSIS 


541 


T-\BLE  75. — Influence  of  Locality  on  Age-Incidence  of  Ttiberculosis 


Lapage.i  Manchester 


Veeder  and  Johnson, 2  St.  Louis 


Age 

Number 
of  cases 

Positive 
reactions, 
per  cent. 

Age. 

Number 
of  cases 

Positive 
reactions, 
per  cent. 

0-2    yrs 

2-5    yrs 

5-10  yrs 

10-14  yrs 

103 
209 
446 
242 

32.0 
51.2 
60.6 
60.8 

Under  1  yr 

1-2    yrs 

2-4    yrs 

4-6    yrs 

6-8    yrs 

8-10  yrs 

10-12  yrs 

202 
109 

163 
172 
152 
126 
107 
94 

1.5 
5.5 
19.0 
23.0 
29.0 
30.0 
34.0 

12-14  yrs 

38.0 

Total 

Total 

1000 

55.7 

1125 

21.0 

Hamburger  and  Monti,^  Vienna 

M'Neill,*  Edinburgh 

Age 

Number 
of  cases 

Positive 
reactions, 
per  cent. 

Age 

Number 
of  cases 

Positive 
reactions, 
per  cent. 

Under  1  yr 

1-2    yrs 

2-3    yrs 

3-4    yrs 

4—5    vrs 

23 
46 
56 
75 
50 
63 
46 
30 
35 
26 
29 
19 
17 
17 

0.0 
9.0 
20.0 
32.0 
52.0 
51.0 
61.0 
73.0 
71.0 
85.0 
93.0 
95.0 
94.0 
94.0 

Under  1  yr 

64 
61 

75 
52 
79 
40 

14  1 

1-2    yrs 

29  9 

3-4    yrs 

46.6 

5—6    yrs 

28  8 

7-10  yrs 

51  9 

5-6    yrs 

6-7    yrs 

7-8    yrs 

8-9    vrs 

11-14  yrs 

1 

55.0 

9-10  vrs 

10-11  vrs 

11-12  vrs 

12-13  yrs 

13-14  yrs 

The  cases  of  Lapage  showed  in  some  instances  cHnical  evidences  of 
tuberculosis;  those  of  Veeder  and  Johnson  and  of  Hamburger  and  Monti 
did  not;  those  of  M'Neill  were  unselected.  The  cutaneous  test  was  the 
one  employed  in  nearly  all  instances;  occasionally  the  intracutaneous 
method  was  used. 

The  obtaining  of  a  positive  tuberculin-reaction  is  not  a  proof  that  the 
clinical  manifestations  which  the  child  may  exhibit  necessarily  depend 
upon  tuberculosis,  but  only  that  this  disease  exists  somewhere  in  the 
system,  perhaps  as  a  small,  entirely  inactive  focus.  It  is  also  probable 
that  children  of  the  better  classes,  and  not  examined  when  suffering  from 
any  symptoms,  would  not  give  a  positive  reaction  so  often.  However  this 
may  be,  the  frequency  with  which  tuberculous  lesions  are  found  in 
children  dying  from  other  disorders,  and  the  large  number  of  cases  in 
which  a  positive  tuberculin-reaction  is  obtained  in  those  apparently 
without  tuberculous  disease,  appears  to  favor  the  view  of  Schlossmann^ 

1  Brit.  Jour.  Child.  Dis.,  1912,  IX,  493. 

2  Amcr.  Jour.  Dis.  Child.,  1915,  IX,  47S. 
»  Miinch.  mod.  Wooh.,  1909,  LVI,  449. 

'  Edinburgh  Med.  Journ.,  1912,  I,  324. 
6  Munch,  med.  Woch.,  1909,  LVI,  398. 


542 


THE  DISEASES  OF  CHILDREN 


and  of  Hamburger  1  that  tuberculosis  is  to  a  large  extent  a  children's 
disease,  acquired  in  childhood  and  often  recovered  from  at  this  time; 
although  it  may  in  other  cases  lie  dormant  and  break  out  actively  in 
adult  life. 

Exciting  Cause. — That  the  disease  is  an  infectious  one  was  believed 
from  early  times,  but  was  first  clearly  proven  by  Villemin  in  1865.^  That 
it  was  dependent  upon  the  tubercle  bacillus  was  first  demonstrated  by 
Koch  in  1882.^  Most  authors  agree  that  there  appear  to  be  two  varieties 
of  the  bacillus  capable  of  producing  the  disease  in  man :  the  bovine  and 
the  human.  The  relationship  and  relative  importance  of  these  is  still 
a  subject  of  much  discussion.  It  appears  to  be  proven  that  the  human 
bacillus  can  occasionally  cause  tuberculosis  in  cattle.  In  like  manner,  the 
bovine  germ  can  certainly  produce  the  disease  in  man,  but  the  large 
majority  of  cases  owe  their  origin  to  the  human  variety.  This  would 
seem,  at  least,  to  be  the  most  frequent  experience,  although  certain 
investigators,  notably  of  Scotland,  among  them  Mitchell,^  Fraser,"  and 
others,  insist  on  the  etiological  importance  of  the  bovine  bacillus  especially 
in  children,  and  chiefly  in  the  production  of  tuberculosis  of  the  cervical 
and  mesenteric  glands  and  of  the  bones  and  joints.  There  would  appear 
to  be  a  difference  in  the  prevalence  of  the  two  forms  of  the  bacillus  in 
different  countries,  since  in  the  United  States,  at  least,  infection  by  the 
bovine  bacillus  is  very  much  less  frequent.  Park  and  Krumwiede's^ 
statistics  show  that  tuberculosis  of  the  lungs,  meninges  and  osseous  sys- 
tem in  children  is  nearly  always  of  human  origin,  but  that  the  disease  in 
the  intestines  and  the  cervical  glands  is  not  infrequently  caused  by  the 
bovine  type;  and  that  there  is  a  greater  tendency  for  bovine  tuberculosis 
to  develop  in  children  than  in  adults.  Their  statistics  are  based  upon 
their  own  and  collected  reports  of  cases,  and  equal  1511  examinations  in 
all,  or  545  in  subjects  up  to  16  years  of  age.  The  following  table  is  taken 
from  their  publication. 

Table  76. — Incidence  of  Human  and  Bovine  Tuberculosis,  Respectively 


Diagnosis 


Children  5  to  16 
years 


Human      Bovine 


Children  under  5 
years 


Human      Bovine 


Pulmonary  tuberculosis {      14 

Tuberculous  adenitis    (axillary  or  inguinal) j        4 

Tuberculous  adenitis  (cervical) 36  22 

Abdominal  tuberculosis 8  9 

Generalized  tuberculosis  of  alimentary  origin ....  3  4 

Generalized  tuberculosis 5  1 

Generalized  tuberculosis  including  meningitis;  ali-  ! 

mentary  origin -.••.••. '        ^ 

General  tuberculosis  including  meningitis :  .  10 

Tuberculous  meningitis I        3 

Tuberculosis  of  the  bones  and  joints j      41      |        3 

Genito-urinary  tuberculosis [        2      i 

Tuberculosis  of  the  skin i        4  6 

Miscellaneous i      . .      i        1 


35 

2 

15 

10 

17 
74 

5 

76 

28 
27 

2 
1 


24 
14 
15 

7 

10 
1 
4 


1  Miinch.  med.  Woch.,  IfiOS,  LV,  2702. 

2  Gaz.  hebdom,  1865,  II,  795. 

3  Berlin,  klin.  Woch.,  1882,  XIX,  221. 

4  Edinburgh  Med.  Journ.,  1914,  XIII,  209. 
6  Journ.  Exper.  Med.,  1912,  XVI,  4,32. 

6  Journ.  Med.  Res.,  1912-13,  XXVII,  109. 


TUBERCULOSIS  543 

Th-^  germs  are  found  in  tuberculous  lesions  wherever  situated  and  in 
the  secretions  and  excretions  from  the  affected  tissues,  particularly  when 
the  process  is  active.  Outside  of  the  body  they  are  widely  diffused 
and  very  abundant,  the  chief  source  being  the  sputum,  in  which  they  are 
present  in  enormous  numbers.  They  are  capable  of  living  and  remaining 
virulent  for  weeks  in  a  dried  state  in  the  dust  from  rooms  occupied  by 
consumptive  patients  (Cornet),^  but  are  killed  by  a  temperature  of  60°C. 
(140°F.)  continued  for  from  15  to  20  minutes.  The  general  opinion  is 
that  they  are  seldom  to  be  found  in  the  blood. 

Mode  of  Transmission  and  Portal  of  Entry. — Except  for  the  rare 
cases  of  congenital  tuberculosis  in  which  the  infection  is  through  the  blood, 
and  the  exceptional  cases  of  tuberculosis  by  direct  inoculation,  as  by 
ritual  circumcision  or  through  other  lesions  of  the  skin,  the  geim  enters 
the  body  either  by  the  respiratory  or  the  alimentary  tract.  When  in- 
fection is  b}^  the  inspired  air,  the  tubercle  bacilli,  often  attached  to  par- 
ticles of  dust  or  to  fine,  moist  drops  expelled  by  the  coughing  of  some 
patient,  are  deposited  upon  the  mucous  membrane  of  the  nasopharynx, 
larynx,  trachea,  bronchi  or  lungs.  If  any  catarrhal  or  other  lesion  exists 
the  penetration  of  this  membrane  is  rendered  much  easier,  but  it  can 
take  place  without  a  lesion  being  present.  It  has  been  believed  that  a 
tuberculous  infection  either  may  develop  at  the  site  of  invasion,  or 
that  the  germs  may  pass  through  the  mucous  membrane  without 
injury  to  it.  It  is  probable,  however,  as  maintained  by  Parrot,^  Kiiss,^ 
Albrecht,^  Ghon^  and  others,  that  the  primary  tuberculous  lesion  is 
always  situated  at  the  portal  of  entry,  although  it  may  be  small  and 
undiscovered  except  by  the  most  careful  search.  This  appears  to  be  the 
present  prevailing  opinion.  The  lesion  here  suffers  the  usual  changes  of 
caseation,  calcification  or  softening,  and  from  this  focus  the  bacilli  travel 
by  way  of  the  lymphatic  vessels  to  the  regional  lyriiphatic  glands,  usually 
the  tracheobronchial.  These  act  as  sieves  and  may  arrest  the  further 
progress  of  the  germs,  which  can  lie  dormant  here  for  an  indefinite  time, 
as  shown  by  the  investigations  of  Loomis,®  Pizzini,^  Beitzke^  and  others, 
exerting  no  influence  whatever  on  the  general  health,  although  the  con- 
dition is  an  ever-present  menace.  Infection  of  the  organs,  or  of  the  sys- 
tem at  large,  is  the  result  of  the  inflammatory  process  increasing  in  the 
primary  focus  or  in  the  lymphatic  glands,  and  the  bacilli  extending  thence 
by  way  of  the  lymphatics;  or  by  the  process  finally  involving  the  blood- 
vessels, and  the  germs  then  entering  the  blood-current. 

When  the  infection  is  by  the  alimentarj^  tract  the  bacilli  enter  from  the 
pharynx,  tonsils,  esophagus,  stomach,  or  intestine,  being  attached  to  the 
food,  or  obtained  from  toys  and  the  like,  or  even  from  the  infant's  fingers. 
As  with  the  respiratory  tract  there  is  usually  a  tuberculous  lesion,  al- 
though small,  at  the  portal  of  entry.  When  the  intestine  is  the  seat  of 
the  primary  lesion,  the  bacilli  pass  thence  into  the  mesenteric  glands  and 
finally  to  other  parts;  when  entrance  is  by  way  of  the  tonsilar  tissue  the 
cervical  glands  generally  arrest  further  extension  of  the  disease. 

Whether  infection  by  the  respiratory  or  the  alimentary  tract  is  the 

1  Zeit.  f.  Hvg.,  1888,  V,  191. 

2  Compt.  rend.  hoc.  de  biol.  do  Paris,  187(5,  III,  30S. 

'  De  rh6r(5dit('!  parasitaire  de  la  tuberculot-e  huniaino,  Paris,  1898.     Rff.  Ghon. 

*  Wicn.  klin.  Wochcnsclir.,  1909,  XXII,  :J27. 

'  Die  primilre  Luiigenlierd  bei  dcr  Tuberculosa  der  Kinder,  Berlin,  1912. 

•  Med.  Rec,  1890,  XXXVIII,  (i.s9. 

7  Zeitschr.  f.  klin.  Med.,  1892,  XXI,  329. 
«  Virchow's  Archiv.,  1912,  CCX,  173. 


544  THE  DISEASES  OF  CHILDREN 

more  frequent  in  children  has  been,  and  still  is,  a  subject  of  widespread 
discussion.  Except  in  the  British  statistics  there  is  little  question,  as 
post-mortem  examination  has  repeatedly  shown,  that  primary  lesions  are 
much  more  often  found  in  the  region  of  the  respiratory  tract,  including 
the  tracheobronchial  lymph-glands  (see  p.  556),  and  a  logical  conclusion 
would  appear  to  be  that  the  gland-filter  situated  nearest  to  the  portal 
of  entry  will  be  the  one  first  affected.  On  the  other  hand,  it  has  been 
claimed  by  those  who  maintain  that  infection  by  way  of  the  intestine  is 
the  more  common,  that  the  bacilli  are  not  filtered  out  by  the  mesenteric 
glands,  but  are  carried  to  the  general  circulation  by  the  thoracic  duct  and 
finally  are  deposited  in  the  lungs  and  the  tracheobronchial  glands,  which 
are  the  parts  most  susceptible  to  the  disease  in  early  life;  and  that  con- 
sequently apparently  primary  lesions  of  these  glands  do  not  exclude 
the  possibility  of  alimentary  infection. 

Even  experimental  evidence  is  contradictory.  Thus,  as  illustrating 
the  opposing  views,  Straus^  showed  that  tubercle  bacilU  injected  into  the 
stomach  readily  cause  a  general  tuberculosis,  and  Calmette,  Guerin 
and  Delearde^  that  respiratory  involvement  could  be  produced  in  this 
way  without  any  affection  of  the  mesenteric  glands.  On  the  other  hand 
Cornet,^  Pfeiffer  and  Friedberger,^  and  Findlay^  demonstrated  the  great 
ease  with  which  respiratory  tuberculosis  could  be  brought  about  by  inhala- 
tion experiments,  and  that  injection  of  germs  into  the  stomach  produced 
tuberculosis  with  difficulty. 

Directly  bearing  upon  this  matter  is  the  question  of  the  danger  of 
milk  from  tuberculous  cattle.  That  this  exists  has  been  practically 
denied  by  Koch,'^  but  affirmed  by  von  Behring^  and  other  investigators. 
The  preponderance  of  the  evidence  at  the  present  time  seems  to  indicate 
that  infection  with  the  bovine  bacillus  contained  in  milk  from  tuberculous 
cattle  is  a  possibility,  but  comparatively  infrequent ;  and  that  the  danger 
is  much  over-rated.  Cattle  which  react  to  tuberculin  but  reveal  no 
tuberculous  foci  usually  have  no  bacilli  in  their  milk.  The  same  is 
true  of  infection  by  the  human  bacillus  in  the  milk  of  tuberculous  mothers. 
More  is  to  be  feared  from  the  contamination  of  cows'  milk  by  the  human 
bacilh  which  may  enter  it  from  the  air,  just  as  they  may  contaminate 
any  other  article  which  enters  the  infant's  mouth.  At  the  same  time 
it  is  unwise  to  employ  milk  from  tuberculous  cattle;  and  whether  or  not 
the  milk  from  a  tuberculous  mother  is  dangerous,  the  intimate  association 
of  the  infant  with  her  certainly  is  so,  and  should  be  prevented.  As 
regards  the  flesh  of  tuberculous  cattle,  infection  by  it  is  perhaps  possible, 
but  certainly  unlikely. 

Pathological  Anatomy.  The  Histology  of  Tubercle. — The  basis 
of  the  pathological  changes  of  tuberculosis  is  the  miliary  tubercle,  which 
is  produced  by  the  irritation  of  the  rapidly  multiplying  bacilH.  It 
consists  of  a  grey,  translucent  body  about  }io  to  ^^  inch  (0.127  to  0.5  cm.) 
in  diameter  surrounded  by  a  reticulum  of  connective  tissue,  and  composed 
of  lymphoid  and  epithelioid  cells  the  result  of  proliferation  of  the  tissue 
cells,  and  of  leucocytes,  at  first  polymorphonuclear,  later  chiefly  mono- 

1  Arch.  med.  exper.,  1896,  VIII,  689. 

2  Compt.  rend.  acad.  sci.,  CXLII,  No.  21.  Ref.  Zentralbl.  f.  inn.  Med.,  1906, 
XXVII,  1090. 

3  Nothnagel's  Encyclop.  Pract.  Med.  Tuberc,  98;  143. 
^  Deutsch.  med.  Wochenschr.,  1907,  XXXIII,  1577. 

6  Zeit.  f.  Kinderh.,  Orig..  1913,  VIII,  503. 

«  Brit.  Med.  Journ.,  1902,  II,  1885. 

'  Deutsch.  med.  Wochenschr.,  1903,  XXIX,  689. 


TUBERCULOSIS  545 

nuclear,  migrating  from  the  neighboring  blood-vessels.  Bacilli  are 
present  in  some  of  the  epithelioid  cells.  In  some  of  the  tubercles  giant 
cells  are  also  found,  their  number  being  inversely  proportional  to  the 
number  of  bacilli  present.  The  tubercles  may  remain  scattered  and 
mostly  separated  from  each  other,  or  may  be  grouped  in  large  masses. 
As  growth  progresses  degenerative  changes  take  place.  Caseation  is 
the  most  common,  the  tubercle  becoming  yellow,  containing  many 
bacilli,  and  finally  softening.  This  is  followed  by  an  inflammation 
of  the  surrounding  tissue  and  the  formation  of  pus  through  a  mixed 
infection.  Less  frequently  calcification  occurs,  seen  oftenest  in  the  lym- 
phatic glands.  Sometimes,  especially  if  the  tubercles  remain  discrete 
and  miliary,   sclerosis  takes  place,   a  firm  fibrous  structure  resulting. 

Regions  Oftenest  found  Affected  by  Tuberculosis  at  Different 
Periods  of  Infancy  and  Childhood. — Age  is  a  prominent  factor  in  this 
connection.  It  is  to  be  borne  in  mind  that  the  process  is  seldom  limited 
to  any  one  locality,  and  that  the  region  most  frequently  attacked  does  not 
necessarih^  produce  the  most  important  symptoms.  In  fact,  tuberculosis 
may  be  only  a  post-mortem  finding,  death  being  dependent  upon  some 
other  disease.  Taking  infancy  and  childhood  as  a  whole,  the  statistics 
compiled  by  Freeman^  in  2288  autopsies  in  tuberculous  children  reported 
by  different  observers  show  involvement  of  the  lungs  in  from  71  to  100  per 
cent.;  of  the  bronchial  lymph-nodes  in  from  76  to  99  per  cent.;  of  the  in- 
testines in  from  23  to  55  per  cent.;  and  of  the  mesenteric  lymph-nodes 
in  from  16  to  40  per  cent. 

In  the  first  2  years  of  life  the  regions  oftenest  found  diseased  are  the 
bronchial  lymphatic  glands,  lungs,  and  pleura.  The  tubercles  may  be 
scattered  over  the  surface  of  the  lung  or  may  involve  a  small  part  of  its 
parenchj'ma.  ]\Iost  frequently  there  develop  the  lesions  of  acute  or 
subacute  tuberculous  bronchopneumonia,  and  less  often  those  of  miliary 
tuberculosis  of  the  entire  lung.  There  may  be  numerous  small  cavities; 
but  the  formation  of  large  cavities,  as  seen  in  phthisis,  is  less  common  at 
this  period.  The  bronchial  glands  are  more  or  less  enlarged  and  cheesy, 
and  not  infrequently  suppurate.  Sometimes  only  a  few  are  affected; 
sometimes  large  masses  of  much  enlarged  glands  are  present.  Involve- 
ment of  the  mesenteric  glands  is  less  frequent  than  that  of  the  bronchial; 
that  of  the  cervical  glands  not  as  common  as  later.  Tuberculous  men- 
ingitis is  very  frequent,  seen  oftenest  in  combination  with  other  clinical 
manifestations,  especially  those  of  bronchopneumonia  or  of  a  general 
tuberculosis.  Stirnimann^  found  the  latter  in  54.4  per  cent,  of  42  cases 
in  591  autopsies  in  the  1st  year  of  life.  Tuberculosis  of  the  peritoneum, 
the  intestine,  and  the  bones  is  not  frequent  in  infancy.  At  this  period 
of  life  there  is  especially  to  be  noted  the  tendency  for  tuberculosis  to 
become  widespread.  Raczynski'*  states  that  in  611  cases  of  tul^orculosis 
as  seen  at  autopsy,  up  to  3  ycftrs  about  50  per  cent,  had  i\  general 
tuberculosis. 

In  earhi  childhood,  from  the  3d  to  the  5th  year  inclusive,  general 
tuberculosis  and  meningitis  remain  very  common,  and  involvement  of 
the  cervical  and  mesenteric  glands,  and  of  the  intestine,  peritoneum  and 
bones  increases  in  frequency.  Tuberculosis  of  the  lungs  is,  however, 
probably  the  most  common  form,  with  that  of  the  pleura  and  bronchial 
glands  nearly  as  often  seen  as  this. 

1  Med.  News,  190.5,  Mav  27. 

2  Jahrb.  f.  Kindorh..  lOOO,  LXIII.  130. 

3  Jahrb.  f.  Kinderheilk.,  1901,  LIV,  67. 
35 


546  THE  DISEASES  OF  CHILDREN 

In  later  childhood  tuberculous  meningitis,  although  still  frequent,  is 
not  so  often  observed  as  in  earlier  childhood.  Cervical  adenitis  and 
involvement  of  the  bones  and  joints  remain  common,  while  tuberculous 
peritonitis  is  increasingly  often  seen. 

The  kidneys,  liver  and  spleen  may  show  miliary  tubercles  on  their 
surface  at  any  age  in  cases  of  general  miliary  tuberculosis.  The  larynx 
is  seldom  involved.  The  pancreas,  thyroid,  thymus,  heart,  and  genito- 
urinary tract  are  regions  only  exceptionally  attacked  in  early  life.  In 
general,  there  is  a  predisposition  at  this  age  to  involvement  of  the  glands, 
while  in  adults  the  mucous  membranes  are  oftener  attacked. 

Seat  of  the  Primary  Lesions. — This,  of  course,  can  be  merely  surmised 
in  many  instances.  Reference  is  not  made  here  to  the  original  lesion  at 
the  portal  of  entry,  often  small  and  undiscovered,  but  to  those  lesions 
readily  seen  and  having  the  appearance  of  having  existed  longest,  and 
from  which  the  extension  of  the  process  could  be  considered  to  have  taken 
place.  In  200  autopsies  on  tuberculous  children,  reported  by  Northrup^ 
and  by  Bovaird,^  this  oldest  lesion  was  in  the  respiratory  tract,  including 
the  bronchial  glands,  in  148,  and  in  the  intestines  and  mesenteric  glands 
in  3.  In  119  autopsies  on  tuberculous  children  published  by  Holt^  the 
oldest  lesion  was  in  no  instance  in  the  intestinal  tract,  and  in  63  per  cent, 
of  the  cases  there  was  no  intestinal  involvement  whatever.  In  115  autop- 
sies on  tuberculous  children  in  the  Children's  Hospital  of  Philadelphia, 
recorded  by  Hand'*  apparently  primary  lesions  of  the  intestine  or  mesen-  ■ 
teric  glands  were  found  in  10.  In  335  autopsies  on  children  with  tuber- 
culous lesions  reported  by  Hamburger'^  there  was  no  certain  case  of 
primary  intestinal  or  mesenteric  tuberculosis.  Albrecht*^  in  1060  autop- 
sies showing  tuberculosis  in  children  found  only  0.66  per  cent,  exhibiting 
undoubted  primary  intestinal  tuberculosis.  All  these  figures  indicate 
the  great  preponderance  of  lesions  in  the  respiratory  tract  as  generally 
observed. 

On  the  other  hand,  British  statistics  show  somewhat  different  figures. 
J.  W.  Carr^  found  in  120  autopsies  79  with  primary  respiratory  lesions, 
and  20  with  primary  intestinal  or  mesenteric  glandular  involvement; 
and  Still*^  in  269  cases  noted  the  primarj'-  localization  as  follows:  Lungs 
138;  intestines  63;  bones  and  joints  5;  ear  15;  unknown  situation  46. 
The  contrast  between  British  and  American  experience  is  well  illustrated 
in  the  collected  statistics  published  by  Bovaird^  as  follows: 

Table  77.— Intestinal  Tuberculosis;   English   and   American   Statistics 

TasP^  '        Primary  p  . 

'^^^^^         I      intestinal       |       ^^^  *'®"^- 

English i        1161  236  20.33 

American 620  21  3.39 

In  addition  is  to  be  mentioned  the  occasional  occurrence  of  the 
primary  locaUzation  in  the  tonsils  or  adenoids,  Wood '"finding  tuberculosis 

»  New  York  Med.  Journ.,  1891,  LIII.  201. 

2  New  York  Med.  Journ.,  1899,  LXX,  ]. 

3  Med.  News,  1896,  LXIX,  656. 

4  Arch,  of  Ped.,  1903,  XX,  248. 

5  Wien.  klin.  Wochenschr.,  1907,  XX,  1069. 

6  Wien.  klin.  Woch.,  1909,  XXII,  327. 

7  Lancet,  1894,  I,  1177. 

"  Pediatrics,  1899,  VIII,  335. 
9  Pixth  Internat.  Cong.  Tuberc,  1908,  II,  4,  451. 
1°  Journ.  Amer.  Med.  Assoc,  1905,  XLIV,  1425. 


TUBERCULOSIS 


547 


suasiM/. 


'Ii_ 


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%l 


lA 


:$-; 


m 


in  5.2  per  cent,  of  1671  collected  cases  in  which  examination  was  made 
of  the  tonsillar  tissue  removed  from  individuals  apparently  free  from 
the  disease  in  other  respects.  Doubtless  these  organs  are  oftener  the 
primary  seat  than  has  usually  been  supposed. 

Lesions  Oftenest  Producing  Death, — -It  by  no  means  follows  that  the 
parts  oftenest  affected  are  those  the  disease  of  which  occasions  the  death 
of  the  patient.  Thus,  in  infancy,  although  pulmonary  involvement, 
usually  in  the  form  of  bronchopneumonia, 
is  the  most  frequent  cause  of  death,  in 
many  pulmonary  cases  the  fatal  issue 
depends  actually  upon  a  general  miliary 
tuberculosis,  or,  oftener,  a  tuberculous 
meningitis.  Involvement  of  the  bron- 
chial lymphatic  glands,  although  so 
frequent,  rarely  produces  fatal  symptoms. 
In  early  and  later  childhood  meningitis, 
secondary  to  involvement  of  the  lungs, 
bones,  or  lymph  glands,  very  often  oc- 
casions the  fatal  termination.  Shennan^ 
found  this  true  in  44.5  per  cent,  of  413 
cases  of  tuberculous  disease  of  various 
sorts  in  children.  Tuberculous  perito- 
nitis is  also  a  not  infrequent  cause  of 
death  in  later  childhood,  while  tuber- 
culous pleurisy,  although  common,  is 
rarely  in  itself  fatal. 

Clinical  Forms  of  Tuberculosis. 
{A)  General  Tuberculosis. — This 
form  consists  in  a  widespread  develop- 
ment of  tubercles  secondary  to  some 
small  caseous  area.  Through  the  en- 
trance of  large  numbers  of  bacilli  into 
the  blood  the  disease  is  spread  more  or 
less  widely  throughout  the  body,  the 
extent  varying  greatly  with  the  case. 
Sometimes  the  various  organs  are 
crowded  with  tubercles,  especially  well 
seen  in  the  lungs;  sometimes  these  are 
much  more  scattered  and  fewer.  The 
symptoms  and  the  rapidity  of  the 
course  of  the  disease  vary  accordingly. 
The  liver  is  oftener  affected  in  children 
than  in  achilts.  The  tubercles  are  com- 
monly larger  in  the  child  than  in  the 
adult  and  in  the  less  rapid  cases  assume 

a  considerable  size  through  confluence,  many  of  them  becoming  caseous 
and  breaking  down.  This  variety  of  the  disease  may  exhibit  itself  in  two 
forms,  (1)  the  Typhoid  and  (2)  the  Marantic. 

1.  The  Typhoid  Form;  Acute  Miliary  Tuberculosis.-  This  is  seen 
chiefly  in  infancy  and  early  childhood.  The  initial  symptoms  are  very 
vague,  consisting  of  loss  of  appetite,  debility,  loss  of  weight,  and  other 
evidences  of  a  general  impairment  of  health.  Fever  of  an  irregular  and 
uncharacteristic  type  soon  develops;  del)ility  increases;  the  tongue 
1  Sixth  Intcrnat.  Cong.  Tubcrc,  1908,  II,  4,  367. 


Fig.  173. — General  Tiberculosis, 
Typhoid  Form. 
George  D.,  aged  5^^  years, 
colored.  Jan.  8.  In  bed  for.  a 
week  with  fever  and  debiUty.  Is 
apathetic,  weak,  tongue  coated.  No 
physical  signs  in  chest  or  abdomen. 
Typhoid  fever  suspected.  Jan.  14, 
gradually  increasing  somnolence, 
slight,  varying  rigidity  of  limbs, 
leucocytosis  7410,  negative  Widal 
reaction;  Jan.  1(5,  undoubted  slight 
signs  of  consolidation  in  right  lung. 
Death.  Autopsy  showed  general 
miliary  tuberculosis. 


548 


THE  DISEASES  OF  CHILDREX 


becomes  dry;  the  pulse  and  respiration  are  accelerated;  there  is  apathy, 
dullness,  sometimes  delirium  and  finally  coma.  The  tympanites  anil 
enlarged  spleen  may,  with  the  continued  fever  and  other  synqitoms, 
strongly  suggest  typhoid  fever  (Fig.  173).  In  other  cases  the  tomjiera- 
ture  is  almost  too  irregular  for  this  disease,  ami  often  only  slightly  or. 
exceptionally,  not  at  all  elevated.  No  cause  for  the  symptoms  can  be 
found.     Temporary  improvement  may  occur,  althougli  the  enuiciation 


Fig.    174. — General    TtBEHcrLosis,    Marantic     Form.     Final    liRONCHOPNEUMONiA 

AND  Miliary  Tiberculosis. 
Chas.  McL.,  aged  1  year.  Said  to  have  been  ill  for  6  months.  Been  siiCfcrinK  hittcrly 
from  fever,  loss  of  weight,  slight  coukIi,  poor  appetite  and  loose  stools.  K.vanii nation. — 
Greatly  emaciated;  anemic;  enlarged  cervical,  axillary,  inguinal  and  abdominal  glands; 
possible  slight  impairment  of  percussion  resonance,  and  harsh  res[)iration;  distended 
abdomen.  Later  positive  e\idence  of  pulmonary  involvement.  Had  daily  a  moderate 
number  of  .soft  or  litiuid  undigested  stools.  Death  about  1  month  later.  Aulopsy. — 
Tuberculou.s  bronchopneumonia  of  left  lung  and  root  of  right  lung;  miliary  tuberculosis 
both  lungs  and  of  the  spleen;  tuberculous  alteration  of  intestine;  adenitis  of  mesenteric, 
retroperitoneal  and  bronchial  glands. 

does  not  disappear  nor  the  strength  greatly  increase.  Finally  some  local- 
izing symptoms  may  develop,  especially  those  of  puhnonary  consoli- 
dation or  of  meningitis;  los.s  often  of  peritonitis.  The  c()uis(>  of  the 
disease  is  rapid,  death  occurring  usually  in  a  few  weeks.  The  (hlTerential 
diagnosis  is  extremely  difficult.  Suggestive  of  tulx'rculosis  is  the  more 
irregular  fever,  the  tendency  to  rapid  respiration,  the  failure  of  the  fever 
to  lessen  at  the  end  of  3  or  4  weeks,  and  especially  the  persistent  absence 
of  the  AVidal  reaction.     Finally  the  develo[)ment  of  localizing  symptoms 


TUBERCULOSIS 


549 


may  make  the  diasiiiosis  of  tuht'iculosis  almost  certain;  hut  this  occurs 
generally  only  a  tew  days  before  death. 

2.  The  Marantic  Form. — Infants  not  infr(>(iuently  exhibit  a  somewhat 
more  chronic  foini  of  tuberculosis,  ch)sely  simulating  marasmus.  The 
symptoms  are  entirely  uncharacteristic,  profiressive  wasting-  and  anemia 
being  the  j)rin('ipal  ones.  There  is  no 
fever,  or  occasional  and  irregular  eleva- 
tions, and  no  respiratory  or  gastroin- 
testinal disturbances  su(lici(Mit  to  account 
for  the  condition.  The  ilisease  can  in  no 
way  be  distinguished  from  other  nui- 
rantic  states,  unless  the  ease  comes  to 
autopsy.  In  other  instances  there  de- 
velops a  few  weeks  l)efore  the  end  of 
life  mor(>  or  less  constant  but  moderate 
f(^ver  of  ii'regular  type,  with  slight 
.symptoms suggesting  bi-oiu;hopiieumonia 
(Fig.  174).  The  resi)irat  ion  is  somewhat, 
accelerated  yet  seldom  decidedly 
dyspneic,  there  is  slight  cough,  and  the 
physical  signs  in  the  lungs  iirv  usually 
not  well-marked,  or  only  those  of  bi'on- 
chitis.  Sometimes  vomiting  or,  es- 
pecially, dianhea  may  become  trouble- 
some, or  the  symptoms  of  meningitis 
close  the  scene.  (Jeneially,  howevei-, 
death  appears  to  be  du(>  to  progi-essive 
exhaustion.  The  (U)urse  of  the;  case, 
although  decidedly  more  prolonged  than 
in  the  typhoid  form,  is  brief;  at  longest, 
a  few  weciks  after  contimied  fever  or 
localizing  sym|)t()ms  ap|)ear,  but  often 
much  longer  from  the  (ii'st.  beginning  of 

signs  of  illness.     The  (l.iatiHosis  is  always    ■'='"•    '■    Alxjut    Doc    i.'i,  dcvolopod 
difficult    and  usually   impossible,    unt'il,    •""*'''   '^"''   ^'''"'  '"''''■''    ••'>"t'""^"<l- 
I)erhaps, shortly  befoixi  death.      l"]ven  the 
development  of  signs    of  bronchopneu 
monia    is    not    conclusive,    since    non- 
tuberculous      bronchoi)neumonia     is    so 
fre(iuenlly    ;i    terminal   condition    in   in- 
fant ileati'opliy.    The  piincipal  diagnost  ic 
aid  is  to  be  sought  in  the  history.     'IMie 
(>ntire  absence  of  discovei'able  icason  foi' 
th(;   (uintinued    wasting,   the  absence  of 

(^videncesofchronicor  repeated  intestinal  Ihikciiiciil  of  ilu*  tru.iitM.hiDiicliiui 
autointoxication,  and  the  fact  that  diar-  k''""''-'-  Modomto  .icv.-lui.m.'iit  of 
rhea,  cough,  and  vouiiting  have  followed    ''"''^•■•<''««  ""    «"^;"'-«    '*;  'ivor  ,u,d 

'.,."'       ,,  ,      ^  II-         Hplocii    ftnd    on    tiio    surnico    of    tho 

cma(!iation     ratfier     tlian     preceded     it,    (.cn-hrimi. 

are  i'(\'isons  for  suspecting  lubei-culosis. 

Tlie  tuberculin-test,  may  be  of  value  in  some  cases. 

(Ji)   Ti'hKUCirLosis  OK  Sl'KCMAh    Rk( iloNS.    -  11  (Tc  are   to   be  includrd 

a  large  mimber  of  foiins  of  tuberculosis  in  which  the  disease  is  conlitird 

1(),  or  preponderates  in,  certain  regions  oi'  organs  of  the  body.      Many 

of  the  conditions  will  be  simply  mentioned  l»rieliy,  the  fuller  description 

of  them  being  found  elsewluue. 


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(<>  (  liildri'ii's  Hospital  of  Pliiladolphia, 
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K.ni.riiiiialioii  tin  iidminsidii .  liyspnoa, 
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Aiilopni/. —  IvUnn.serowded  wiili  miliary 
liilierch'.s   lliroiiKliout.      Moderates   en- 


550 


THE  DISEASES  OF  CHILDREN 


1.  Tuberculosis  of  the  Lungs. — Several  varieties  of  this  may  be  seen: 
(a)  Acute  Miliary  Tuberculosis  of  the  Lungs  (Fig.  175). — This  is  the 
form  of  the  general  miliary  tuberculosis  described  in  which  the  locali- 
zation is  most  prominent  in  the  lungs  from  the  onset.  It  is  most  common 
after  the  age  of  infancy.  There  is  persistent  fever  of  irregular  but  not 
hectic  type;  rapid  respiration,  which  is  sometimes  dj^spneic;  prostra- 
tion; rapid  pulse;  cough;  and  sometimes  cyanosis.  The  physical  signs 
in  the  lungs  are  often  poorly  marked  and  uncharacteristic.  Later  the 
evidences  of  tuberculosis  elsewhere  may  show  themselves,  the  child  dying, 
possibly,  from  meningitis.  The  course  of  the  case  is  short.  At  autopsy 
the  lungs  are  found  filled  with  miliary  tubercles. 


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Fig.  176. — Tuberculous  Bronchopneumonia. 
Charles  T.,  aged  1  year.  Is  said  to  have  been  ailing  6  weeks  before  seen.  In  the 
Children's  Hospital  nearly  1  month.  Increasing  impairment  of  percussion  resonance  and 
of  bronchial  respiration  over  both  lungs,  with  numerous  rales.  Increasing  weakness  and 
loss  of  weight,  petechice,  cough,  anorexia,  D'Espine's  sign.  Tubercle  bacilli  found  in  sputum. 
Autopsy. — Bronchial  and  mesenteric  glands  much  enlarged  and  tuberculous.  Caseous 
pneumonia  of  both  lungs.  Cavity  size  of  walnut  in  right  lower  lobe.  Miliary  tuberculosis 
of  spleen  and  of  pleura. 

(h)  Acute  Tuberculous  Bronchopnewnonia. — This  is  one  of  the  most 
frequent  manifestations  of  tuberculosis  in  children.  It  is  seen  oftenest 
in  infancy  and  especially,  in  early  childhood ;  may  be  primary  in  the 
lungs  or  secondary  to  tuberculosis  in  some  other  part  of  the  body,  such 
as  the  bones,  pleura,  peritoneum,  and  particularly  the  bronchial  lymphatic 
glands;  or  may  follow  some  other  disease,  especially  pertussis,  grippe, 
measles,  or  even  bronchitis  or  simple  bronchopneumonia.  The  patho- 
logical lesions  are  the  same  as  those  of  non-tuberculous  bronchopneu- 
monia, with  the  addition  of  the  presence  of  tubercle  bacilli  and  the 
development  of  tubercles  and  of  the  degenerative  changes  which  subse- 
quently take  place  in  these,  and  which  result  in  the  formation  of  many 


TUBERCULOSIS 


551 


smaller  and  larger  caseous  areas,  and  often  finally  of  cavities,  if  life 
continues  a  sufficient  time;  generally  small  and  centrally  located,  but 
sometimes  of  considerable  size.  I  have  seen  a  cavity  as  large  as  an  average 
orange,  occupying  the  entire  upper  right  lobe  in  a  child  of  7  months. 
Occasionally  rupture  into  the  pleural  sac  takes  place.  The  large,  slowly 
developing,  encapsulated  cavities  characteristic  of  phthisis  in  the  adult  are 
usuall}^  absent  in  childhood  until  the  age  of  puberty  is  approached.  With 
the  tuberculous  process  in  the  lungs  is  always  associated  similar  disease 
of  the  bronchial  lymph-nodes.  The  clinical  picture  does  not  differ 
materially  from  that  of  simple  bronchopneumonia.     (See  Bronchopneu- 


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Fig.  177. — Subacute  Tuberculous  Bronchopneumonia  with  Cavity-fokmation. 
("hart  show.s  the  first  and  last  11  days  of  observation  in  hospital. 
William  K.,  aged  11  months  when  admitted  to  the  Children's  Hospital,  Det-.  20,  191G. 
Died  Mar.  18,  1917,  aged  14  months.  Cough  and  debility  since  age  of  3  months.  While 
under  observation  considerable  dulness  on  percussion  throughout  the  right  lung;  many 
crackling  rales  and  feeble  breath-sounds,  not  bronchial.  Before  death  there  developed 
bronchial  respiration  over  the  upper  i)art  of  the  right  lung;  distinctly  cavernous  at  the 
apex.  Aidojjsy  showed  onlargod  bronchial  glaiuls  especially  on  the  right  side;  the  right 
pleura  firmly  adherent;  right  lung  tuberculous  throughout,  a  cavity  tlie  size  of  an  orange 
occupying  the  whole  of  the  upper  lobe. 


monia,  p.  58.)  Very  frequently,  however,  the  onset  is  more  gradual,  the 
principal  early  symptoms  l)eing  cough,  loss  of  weight,  debility,  increa.sed 
rapidity  of  respiration  and  pulse-rate,  and  moderate  fever  of  an  irregu- 
lar type  (Fig.  17()).  Later  dyspnea  becomes  decided;  the  cough  worse; 
the  temperature  higher,  and  there  is  cyano.sis  and  increasing  \v(>akncss. 
The  physical  signs  are  the  same  as  those  of  simple  broncliopncunnonia, 
the  lesions  usually  being  scattered  to  a  varying  extent  throughout  both 
lungs,  aUiiough  most  apparent  in  one.  The  p.scudolobar  form  is  less  often 
seen.  When  localization  occurs  it  is  oftener  in  the  upper  lol)e and  toward 
the  hilus  than  is  the  case  with  simple  broncliopneumonia.     Yet  there  is 


552 


THE  DISEASES  OF  CHILDREN 


such  variation  possible  in  the  symptoms  and  physical  signs  that  the  diag- 
nosis of  the  tuberculous  nature  of  the  case  is  often  impossible.  Sug- 
gestive of  tuberculosis  is  the  development  of  bronchopneumonia  during 
convalescence  from  measles  or  pertussis,  or  after  a  period  of  wasting  and 
ill-health  such  as  occurs  in  the  general  tuberculosis  of  infants;  the 
discovery  of  tuberculosis  elsewhere  in  the  body;  the  failure  of  conva- 


FlG.    178. RaDIO(;HAPH  of  Tl'BEKCULOt.S  Bron'chopneumonia. 

Same  case  as  in  Fig.  177.     Shows  advanced  lesions  of  tuberculous  bronchopneumonia 
in  the  right  lung  and  to  a  less  extent  in  the  left.     Viewed  from  behind. 

lescence  to  begin  at  the  time  which  may  reasonably  be  expected  in 
simple  bronchopneumonia;  and  the  consequently  longer  course,  continuing 
perhaps  for  several  weeks.  Tubercle  bacilli  may  often  be  found  in  the 
secretion  from  the  lungs  (see  p.  560)  or  the  tuberculin-reaction  may  be 
obtained.  In  rare  instances  hemoptysis  may  occur.  I  have,  however, 
seen  a  profuse  hemorrhage  fatal  in  a  few  minutes  in  an  infant  of  14 
months. 

(c)  Subacute  and  Chronic  Pulmonary  Tuberculosis. — This  may  show 
itself  in  several  forms  in  children. 


TUBERCULOSIS 


553 


(a)  Subacute  and  Chronic  Tuberculous  Bronchopneumonia  (Figs. 
177-180). — The  subacute  type  of  this  condition  constitutes  merely  a 
protracted  form  of  acute  tuberculous  bronchopneumonia  and  is  directly 
continuous  with  it.  It  may  last  for  some  months  and  terminate  fatally, 
or  may,  less  often,  pass  into  the  chronic  form.  The  chronic  form  may 
also  develop  without  being  preceded  by  any  well-marked  attack  of  bron- 
chopneumonia. In  some  cases  there  may  have  been  only  attacks  of 
what  was  supposed  to  be  a  bronchitis.     Whatever  the  mode  of  onset, 


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Fig.  179. — Chronic  Tuberculous  Bronchopneu.moni.\. 
George  T.,  23-2  years  old.  Taken  ill  in  summer  of  1916  with  general  poor  health. 
In  the  autumn  symptoms  Of  ileocolitis.  Recovered  irom  this,  but  never  regained  strength. 
Had  dry  cough,  sometimes  troublesome;  accelerated  pulse  and  respiration;  irregular  fever, 
the  last  certainly  from  December.  First  seen  Apr.  4,  1917.  Under  observation  was 
emaciated,  good  appetite,  bowel  movements  generally  normal,  slight  cough,  nasal  ol> 
struction  with  adenoids,  respiration  30  to  40,  fretful,  debilitated,  fever  daily,  positive 
von  Pirquet,  no  tubercle  bacilli  found  in  secretion  obtained  from  throat,  tuberculide  under 
chin,  enlarged  glands  each  side  of  neck.  Repeated  physical  examinations  of  chest  showed 
nothing  abnormal,  except  deficient  expansion;  but  j-ray  examination  (Fig.  ISO)  revealed 
numerous  scattered  lesions.  Went  to'seashorc  May  30,  1917,  with  condition  unchanged, 
and  died  July  24. 

the  recovery  is  not  complete  and  the  child  is  left  with  debility  and  cough. 
Repeated  exacerbations  occur  at  intervals  and  gra(hially  decided  phys- 
ical signs  of  chronic  bronchopneumonia  develop,  if  not  present  previously. 
(See  (Chronic  Bronchopneumonia,  Vol.  II,  p.  i)().)  Exceptionally  the 
disease  may  begin  insidiously,  with  wasting,  continued  fever,  and  more 
or  less  cough.  The  lesions  may  not  be  discoverable,  or  only  un.satisfac- 
torily  so  by  physical  examination;  but  the  r-rny  may  show  numt^'ous 
scattered  areas  (Fig.  ISO).  The  cast^  may  contiruie  for  months  and  ter- 
minate finally  by  exhaustion  or  throiurh  the  development  of  some  acute 
tuberculous  piocess.; 


554 


THE  DISEASES  OF  CHILDREN 


(P)  Hilus  Tuberculosis. — This  is  a  condition  arising  in  connection 
with  tuberculosis  of  the  tracheobronchial  glands,  especially  those  adjacent 
to  the  hilus  of  the  lung.  The  lesion  may  be  primary  at  this  portion  of 
the  lung,  and  in  any  event  the  glands  are  affected  secondarily.  It  may 
develop  at  any  period  of  early  life,  even  infancy.  The  onset  is  insidi- 
ous and  the  symptoms  vague,  consisting  of  malaise,  diminished  appetite, 
debility,  and  possibly  evening  rise  of  temperature.  There  is  a  positive 
tuberculin-reaction,  but  an  absence  of  the  ordinary  physical  signs.     The 


^ 


Fig.  180. — Radiograph  of  Chronic  Tuberculous  Bronchopneumonia. 
Same  case  as  Fig.  179.     Shows  widespread  infiltration  with  numerous  scattered  lesions. 

involvement  of  the  pulmonary  tissue  of  the  hilus  cannot  be  distinguished 
by  physical  examination  from  that  of  the  glands  of  the  hilus  which 
accompanies  it.  The  x-ray  examination  may  show  fine  lines  radiating 
from  the  root  of  the  lung  (Fig.  181),  indicating  probably  an  involve- 
ment of  the  pulmonary  parenchyma  of  the  hilus-region  (Stoll  and 
Heublein).^  The  condition  runs  the  chronic  course  of  tuberculosis  of  the 
tracheo-bronchial  glands. 

(7)  Primary  Pulmonary  Foci  of  Ghon. — The  name  of  Ghon^  is  com- 
monly associated  with  these  lesions,  although  they  were  earlier  described 
by  others.     They  consist  of  small,  round  foci  from  that  of  a  millet  seed 

lAmer.  Jour.  Med.  Sci.,  1914,  CXLVIII,  382. 

2  Der  primJire  Lungenherd  bei  der  Tuberkulose  der  Kinder,  1912. 


TUBERCULOSIS 


555 


to  that  of  a  hazelnut  or  even  larger  in  size  (Albrecht).^  They  are  gen- 
erally single  or  but  few  in  number  and  are  situated  in  different  parts  of 
one  or  both  lungs.  The  lesions  represent  the  seat  of  primary  pulmonary 
involvement.  Any  portion  of  the  lung  may  be  attacked,  although  there 
is  a  somewhat  greater  disposition  to  involve  the  upper  lobe.  They  may 
occur  at  any  period  of  early  life,  but  with  diminishing  frequency  as  in- 
fancy is  past.     The  lesions  may  become  caseous,  calcified,  or  shrunken, 


Fig.  181. — Radiograph  of  Tuberculosis  of  the  Bronchial  Glands  and  of  the  Hilus 

OF  the  Lungs. 
The  ray-like  shadows  indicate  the  infiltration  along  the  course  of  the  bronchial  tubes. 

and  may  continue  for  an  indefinite  time  without  the  production  of  symp- 
toms, although  the  neighboring  lymphatic  glands  are  always  secondarily 
involved.  The  condition  in  this  form  is  of  importance  only  as  indicating 
the  primary  source  of  the  extension  of  tuberculosis  which  later  sometimes 
takes  place. 

Following  another  course,  and  with  increasing  fre(iucncy  in  propor- 
tion to  the  youth  of  the  patient,  the  foci  instead  of  becoming  doiinant 
remain  moderately  active,  the  child  exhil)iting  irregular  or  no  fever, 
debility,    loss    of    weight    and  a    chronic    cough;   physical  signs  being 

»  Wien.  klin.  Wochcnschr.,  1909,  XXII,  327. 


556  THE  DISEASES  OF  CHILDREN      * 

absent  except  perhaps  some  scattered  rales.  The  tuberculin-reaction  is 
positive  and  in  some  cases  tubercle-bacilli  may  be  found  in  the  sputum. 
The  lesions  at  autopsy  consist  of  the  few  foci  described,  which  perhaps 
have  become  broken  down  and  formed  cavities;  the  combined  involve- 
ment of  the  tracheo-bronchial  glands;  and  the  evidences  of  fresh  tuber- 
culous processes  in  the  neighborhood  of  the  foci  or  elsewhere.  The 
prognosis  in  these  more  active  cases  is  uncertain.  The  condition  is  liable 
to  eventuate  in  an  acute  tuberculous  bronchopneumonia  or  a  more  wide- 
spread tuberculosis,  but  especially  in  tuberculous  meningitis, 

(6)  Phthisis. — This  is  the  form  of  the  disease  so  common  in  adult  life. 
It  is  rarely  found  in  infancy  and  early  childhood,  and  even  in  later  child- 
hood it  is  very  much  less  frequent  than  after  this  period.  Statistics  vary- 
considerably,  but  it  is  interesting  to  note  that  Sawyer^  in  a  physical  exami- 
nation of  8000  children  under  15  years  of  age  found  only  15  in  which  a 
diagnosis  of  phthisis  could  be  made  with  reasonable  certainty.  Its 
symptoms,  physical  signs  and  treatment  are  much  the  same  as  those  of 
phthisis  in  adult  life.  Only  to  be  noted  here  is  the  lesser  frequency  of 
cough,  involvement  of  the  larynx,  dyspnea,  and  of  hemoptysis.  The 
disease  is  to  be  distinguished  chiefly  from  chronic  bronchiectasis,  and 
from  those  cases  of  chronic  simple  bronchopneumonia  in  which  the  oc- 
currence of  consolidation  about  a  large  bronchus  strongly  suggests  the 
presence  of  a  cavity.  Abscess  of  the  lung,  too,  may  closely  simulate  it. 
The  obtaining  of  the  tubercle-bacilli  from  the  sputum  or  the  presence  of 
the  tuberculin-reaction  may  settle  the  diagnosis.  The  infrequency  with 
which  cavity-formation  takes  place  in  the  cases  in  children  denominated 
phthisis  by  many  observers  raises  the  question  whether,  strictly 
speaking,  many  of  those  included  in  statistics  should  not  be  considered 
a  chronic  disseminated  tuberculous  bronchopneumonia,  rather  than 
phthisis  as  it  occurs  in  adult  life. 

2.  Tuberculosis  of  the  Lymphatic  Glands.  {Scrofula,  Tabes  Mesen- 
ferica,  etc.). — The  involvement  of  the  lymph-nodes  is  one  of  the  most 
common  forms  of  tuberculosis  in  early  life,  the  frequency  of  its  occurrence 
being  much  greater  than  in  adults.  That  of  the  internal  glands  is  often 
combined  with  evident  tuberculosis  of  other  parts,  the  symptoms  of 
which  give  the  clinical  evidences  of  tuberculous  infection. 

(a)  Tuberculosis  of  the  Tracheo-bronchial  Lymphatic  Glands  (Fig.  181). 
— These  glands  include  those  about  the  trachea  and  the  main  bronchi  and 
those  following  the  major  subdivisions  of  the  bronchus  at  and  beyond  the 
hilus  of  the  lungs.  The  process  may  be  distinctly  secondary  to  lesions 
in  the  lungs;  or  apparently  primary,  although,  in  reality,  dependent  upon 
some  small  undiscovered  pulmonary  tuberculous  focus.  There  are,  as  a 
rule,  few  if  any  clinical  manifestations,  and  the  condition  is  distinguished 
only  post-mortem.  This  is  especially  true  of  infancy,  but  even  after 
this  period  the  clinical  picture  is  generally  indefinite.  In  some  cases  dis- 
tinct evidences  of  pressure  or  of  rupture  of  a  suppurating  gland  become 
manifest.  The  symptoms  will  be  discussed  under  Adenitis.  (See  Vol. 
II,  p.  501.) 

(6)  Tuberculosis  of  the  Mesenteric  Glands  {Tabes  nwsenterica) . — This  is 
a  common  localization  of  tuberculosis  in  children,  although,  as  already 
stated,  much  less  so  than  is  that  in  the  bronchial  glands.  It  may  be 
combined  with  tuberculosis  of  the  intestine,  or  less  frequently  occur  with- 
out evident  lesions  there.  As  a  rule  there  are  no  clinical  manifestations 
apart  from  those  of  other  portions  of  the  body,  especially  the  intestine. 
The  symptoms  will  be  discussed  under  Adenitis.  (See  Vol.  II,  p.  502.) 
1  Brit.  Jour.  Child.  Dis.,  1909,  VI,  205. 


TUBERCULOSIS  557 

(c)  Tuberculosis  of  the  Cervical  Glands. — Tuberculosis  of  the  external 
glands  is  exhibited  in  the  cervical  group  with  much  the  greatest  frequency. 
It  is  especially  common  in  early  and  later  childhood,  less  so  in  infancy. 
The  group  of  symptoms  often  associated  with  and  frequently  preceding  it 
has  for  many  years  been  described  under  the  title  ''Scrofulosis,"  and 
the  term  is  still  employed  in  many  text-books.  The  adenitis  is  usually 
unaccompanied  by  discoverable  evidences  of  tuberculosis  of  the  bones, 
lungs,  or  other  viscera.  The  portal  of  entry  is  probably  the  tonsils, 
adenoid  growths  and  chronic  lesions  of  the  pharynx  (see  p.  543) ;  or  there 
may  occur  much  less  often  an  extension  of  infection  from  the  bronchial 
glands.  In  106  cases  in  which  the  tonsils  were  removed  for  tuberculosis 
of  the  cervical  glands,  Mitchell^  records  infection  of  the  tonsils  in  41. 
Deterioration  of  the  general  health  or  attacks  of  acute  infectious  diseases, 
especially  measles  and  pertussis,  act  as  predisposing  causes.  The  bacilli 
may  be  either  human  or  bovine  in  type.  (See  p.  542.)  The  process  may 
extend  to  the  axillary  and  sometimes  to  other  external  glands.  The 
bronchial  lymph-nodes  have  been  found  involved  in  most  of  the  cases 
coming  to  autopsy.  Apart  from  the  glandular  affection,  symptoms  called 
"scrofulous"  are  described.  The  subject  will  be  further  discussed  under 
Diseases  of  the  Lymphatic  Glands.  (See  Vol.  II, p.  498.)  Hereonlj-may 
be  said  that  since  it  is  certain  that  the  involvement  of  the  glands  in 
''scrofula"  is  invariably  tuberculous,  and  very  possible  that  the  other 
local  conditions  are  in  reality  tuberculous  lesions  also,  the  retaining  of  the 
word  in  the  nomenclature  of  diseases  appears  to  be  unnecessary  and  a 
source  of  confusion. 

(d)  General  Tuberculous  Adenitis. — This  condition  without  other 
clinical  manifestations  is  of  unusual  occurrence  at  any  period  of  life.  In 
it  one  set  of  glands  after  the  other  may  be  attacked  without  other  dis- 
coverable lesions.  The  disorder  is  to  be  distinguished  from  Hodgkin's 
disease.     It  has  been  especially  studied  by  Lesage  and  Pascal.- 

3.  Tuberculosis  of  the  Alimentary  Tract. — The  disease,  as  stated,  not 
infrequently  attacks  the  tonsils  and  adenoid  tissue  and  spreads  thence  to 
the  cervical  glands.  White^  estimates  the  presence  of  tuberculosis  in  5 
per  cent,  of  adenoids.  The  stomach  is  but  rarely  the  seat  of  tuberculosis. 
The  most  frequent  localization  of  alimentary'  infection  in  children  is  in 
the  intestine,  where  the  disease  assumes  the  form  of  ileocolitis.  (See  Intes- 
tinal Ulceration,  p.  798.).  This  is  not  common  in  early  life  after  the  age  of 
infancy.  In  the  majority  of  cases  it  is  secondary  to  involvement  of  the 
lungs,  and  is  usually  associated  with  tuberculosis  of  the  mesenteric  glands. 
The  small  intestine  is  the  region  oftenest  involved,  the  colon  is  sometimes 
secondarily  so,  and  occasionally  the  cecum  is  the  only  part  attacked. 
The  diagnosis  from  other  forms  of  ileocolitis  depends  chiefly  upon  the 
discovery  of  the  tubercle  bacilli  in  the  stools  or  of  tuberculosis  elsewhere 
in  the  body. 

4.  Tuberculosis  of  the  Genito-urinary  Tract. — While  miliary  tuber- 
culosis of  the  kidney  is  frequent  in  cases  of  general  tuberculosis,  clinical 
manifestations  of  tuberculous  renal  disease  are  rare  in  children.  Tuber- 
culosis of  the  testis  is  occasionally  seen  and  more  rarely  of  the  female 
genitals.  That  of  the  penis  has  followed  ritual  circumcision.  Of  this 
occurrence  Reuben*  has  collected  42  reported  instances. 

1  Jour.  Pathol.  luul  Bactoriol..  1917,  XXI,  248. 

2  Arch.  g('n.  dc  inrd.,  lS9;i,  CLXXI,  1,  270. 

»  Amer.  Journ.  med.  Soi.,  1907,  CXXXIV,  228. 
*  Arch,  of  Pediat.,  1917,  XXXIV,  IStJ. 


558  THE  DISEASES  OF  CHILDREN 

5.  Tuberculosis  of  the  Nervous  System. — Apart  from  involvement  of 
the  meninges,  the  nervous  sj'stem  is  not  often  attacked.  Large,  solitary 
tubercles  are  sometimes  found  in  the  brain  or  spinal  cord.  These  may- 
become  cheesy  or  even  calcareous,  and  may  give  rise  to  localizing  symp- 
toms, as  in  the  case  of  tumors  of  other  nature. 

6.  Tuberculosis  of  Serous  Membranes. — This  may  occur  widespread 
as  one  of  the  manifestations  of  general  tuberculosis,  or  may  predominate 
in,  or  be  confined  to,  certain  of  the  serous  membranes,  especially  the 
meninges,  the  peritoneum,  and  the  pleura.  Meningitis  is  very  common 
and  a  frequent  cause  of  death.  It  is  nearly  invariably  secondary  to 
tuberculosis  elsewhere,  although  often  without  symptoms  except  those 
of  meningitis.  It  is  most  frequent  in  later  infancy  and  early  childhood. 
The  clinical  manifestations  will  be  described  under  Meningitis  (Vol.  II, 
p.  326).  In  infancy  involvement  of  the  peritoneum  is  usually  only  one  of 
the  manifestations  of  a  more  general  tulx^rculosis.  After  this  period  tuber- 
culosis may  be  limited  to  the  peritoneum,  or  the  involvement  of  this  be  at 
least  the  chief  cause  of  the  symptoms  observed.  It  may  be  apparently 
primary,  the  lesion  at  the  portal  of  entry  not  i)eing  discovered;  or  much 
oftener  secondary  to  tuberculosis  elsewhere,  as  in  the  mesenteric  glands  or, 
less  often,  the  ^  lungs  or  other  regions.  (8ee  Peritonitis,  p.  852.) 
Tuberculous  pleurisy  with  serous  or  purulent  exudate  is  seen  in  later 
childhood;  less  often  before  this.  Without  eifusion  it  is  of  common 
occurrence  as  one  of  the  symptoms  of  general  tuberculosis,  or  as  an 
attendant  upon  tul^erculosis  of  the  lungs. 

Tuberculosis  of  the  })ones  and  joints  and  of  the  skin  will  be  discussed 
under  the  disorders  of  those  regions. 

Prognosis. ^ — Tuberculosis  is  frequently  stated  to  be  the  cause  of  about 
}<j  of  all  deaths.  The  census  of  the  United  States  published  in  1900 
(Wilbur)^  gives  tuberculosis  as  the  cause  of  death  in  11.22  per  cent, 
of  the  total  mortality,  and  unquestionably  the  actual  proportion  was 
decidedly  larger  than  this.  On  the  other  hand,  a  large  number  of  cases 
which  show  tuberculosis  p.t  autopsy  have  died  of  other  affections.  The 
general  mortaUty  from  tuberculosis  has  without  doubt  diminished  in  recent 
years.  This  is  not  so  much  because  the  patients  recover  more  readily, 
although  this  has  certainly  resulted  from  improved  methods  of  treatment, 
as  because  preventive  measures  have  diminished  the  number  of  cases 
developing.  It  is  noteworthy,  however,  as  demonstrated  by  Behla^  for 
Prussia,  that  the  diminution  in  the  number  of  deaths  from  tuberculosis 
in  children  has  not  kept  pace  with  that  for  later  periods  of  life;  and  the 
same  was  shown  by  Hoffman^  to  be  true  to  some  extent  for  the  Registra- 
tion Area  of  the  United  States. 

The  prognosis  of  tuberculosis  in  children  varies  with  the  age  and 
with  the  form  of  the  disease.  In  the  1st  year  there  appears  to  be  almost 
no  power  of  resistance,  and  the  result  is  nearly  always  fatal;  but  in 
proportion  as  age  advances  this  power  beccxnes  greater  and  arrest  of  the 
process,  permanent  or  temporary,  often  takes  place.  Tuberculous 
bronchopneumonia  is  practically  always  fatal,  either  in  the  first  attack 
or  in  the  relapses  which  are  likely  to  occur.  Only  isolated  cases  of  re- 
covery from  tuberculous  meningitis  have  been  reported,  and  these  may 
have  been  but  temporary  arrests  of  the  disease.  (See  Tuberculous  Menin- 
gitis, Vol.  II,  p.  334.)  On  the  other  hand,  tuberculous  peritonitis  fre- 
quently terminates  favorably,  with  or  without  operation ;  osseous  tuber- 

>  New  York  Med.  Journ.,  1908,  LXXXVIII,  798. 

2  Berl.  klin.  Woch.,  1913,  L,  1951. 

3  Journ.  of  the  Outdoor  Life,  1913,  X,  361. 


TUBERCULOSIS  559 

culosis  is  often  cured;  that  involving  the  bronchial  lymphatic  glands  is  in 
itself  seldom  a  cause  of  death,  and  tuberculosis  of  the  cervical  glands  is 
usually  not  a  condition  which  menaces  life.  The  prognostic  indications 
of  the  tuberculin-reaction  will  be  referred  to  later  (p.  561). 

Diagnosis. — Apart  from  the  manifestations  pertaining  to,  and  the 
characteristics  of  special  localizations  of,  tuberculosis,  there  are  certain 
features  which  are  suggestive  from  a  diagnostic  point  of  view.  Careful 
attention  should  be  given  to  the  histor^y  of  tuberculosis  in  the  family  as 
bearing  upon  the  possibility  of  the  inheritance  of  a  predisposition  to  the 
disease,  or  still  more  of  peculiar  opportunity  for  the  acquiring  of  the  affec- 
tion by  association  with  tuberculous  relatives.  The  existence  of  un- 
favorable hygienic  conditions  is  to  be  sought,  such  as  render  the  subjects 
more  susceptible  or  occasion  unusually  free  contact  with  the  germs.  The 
earlier  occurrence  of  other  diseases  which  may  predispose  is  also  to  be 
considered.  Especially,  in  the  case  of  pulmonary  tuberculosis,  are  to  be 
suspected  previous  attacks  of  pertussis,  measles,  pneumonia,  bronchitis, 
and  grippe.  A  generally  defective  state  of  health  of  the  child,  and  the 
existence  of  the  physiciue  which  is  known  to  be  associated  with  tuber- 
culosis, are  also  of  moment. 

In  the  case  of  active  tuberculosis  of  an  obscure  nature,  the  occurrence 
of  fever  is  important.  In  the  large  majority  of  cases  some  elevation  of 
temperature  is  present  at  times.  It  is  generally  of  an  irregular  type  and 
often  only  slight;  and  is,  of  course,  not  conclusive,  since  so  many 
other  conditions  are  capable  of  producing  it,  especially  in  early  life.  In 
spite  of  this  fact,  the  continual  repetition  of  frequent  rises  of  temperature, 
other  causes  having  been  sought  for  and  excluded  as  far  as  possible,  is 
an  extremely  suspicious  circumstance.  It  is  a  matter  of  common  occur- 
rence, as  I  know  from  my  own  experience,  to  consider  a  general  tuberculosis 
to  be  typhoid  fever,  until  some  distinct  localizing  process  finally  develops; 
and  I  recall  one  instance  in  which  two  eminent  physicians  had  respectively 
made  the  diagnosis,  the  one  of  endocarditis  and  the  other  of  chronic 
intestinal  indigestion  and  toxemia,  and  which  finally  eventuated  in  a 
tuberculous  peritonitis.     Many  analogous  cases  could  easih'  be  detailed. 

A  persistent  increasing  impairment  of  the  general  health  also  arouses 
suspicion,  although  not  necessarily  present  in  many  forms  of  tuberculosis; 
nor  of  certain  indication,  since  it  may  depend  upon  so  many  other  factors. 
Chronic  cough  is  of  diagnostic  value  to  a  limited  extent.  It  may  depend 
upon  many  different  causes,  but  tuberculosis  of  the  lungs  or  pleura  is 
always  to  be  thought  of.  When  paroxysmal  and  stenotic  in  character 
and  associated  with  dyspnea,  it  may  indicate  tuberculosis  of  the  tracheo- 
bronchial glands.  Hemoptysis  is  so  uncommon  in  early  life  that  it  need 
scarcely  be  considered  as  a  possible  diagnostic  sign.  Pleurisy  with 
a  serous  effusion  is  always  suggestive  of  tuberculosis  when  occurring 
in  early  life.  The  discovery  of  nodular  masses  in  the  abdominal  cavity 
points,  in  the  case  of  children,  more  to  tuberculosis  than  to  any  other 
condition,  and  ascites  is  very  probal)ly  tub(>rculous,  if  cardiac  and  renal 
diseases  can  l)e  exclud(Ml. 

The  examination  of  the  blood  is  of  little  diagnostic  value.  Slight 
increase  in  the  number  of  leucocytes  is  sometimes  present,  the  degree 
varying  with  the  form  of  the  disease.  The  only  exception  seems  to  be 
tuberculous  meningitis,  in  which  there  is  not  infre(|uently  a  decided  leuco- 
cytosis.  In  acute  pulmonary  cases  the  absence  of  a  high  polymorphonu- 
clear leucocytosis  tends  to  exclude  pneumonia  of  other  than  tuberculous 
origin. 


560  THE  DISEASES  OF  CHILDREN 

The  x-ray  examination  is  of  very  great  value  in  some  forms  of  tuber- 
culosis, notably  when  it  affects  the  bones  and  joints,  tracheo-bronchial 
glands,  lungs,  and  pleura.  It  must  be  admitted,  however,  that  the  pic- 
tures are  sometimes  misleading,  and  that  the  results  of  the  examination 
must  be  regarded  as  confirmatory  and  the  diagnosis  must  be  in  accord 
with  other  physical  signs  and  symptoms.  The  existence  of  complement- 
fixation  in  tuberculosis  is  not  sufficiently  certain  to  be  depended  upon, 
and  the  same  is  true  of  the  agglutinative  reaction  often  present. 

When  the  disease  is  of  a  nature  which  permits  of  the  discovery  of 
tubercle  bacilli,  the  diagnosis  is,  of  course,  made  certain.  It  is  impor- 
tant, however,  to  be  absolutely  sure  that  the  bacilli  really  are  those  of 
tuberculosis.  They  may  be  found  in  the  large  majority  of  instances  of 
tuberculous  meningitis  and  in  many  cases  of  tuberculosis  of  the  lungs. 
Inasmuch  as  young  children  do  not  expectorate,  special  measures  must  be 
employed  to  obtain  the  sputum.  For  this  purpose  a  swab  of  absorbent 
cotton  or  of  muslin,  firmly  attached  to  a  curved  applicator,  may  be  ap- 
plied to  the  region  of  the  glottis,  and  the  sputum  which  the  consequent 
coughing  brings  up  can  be  caught  upon  this.  Bacilli  may  also  not  in- 
frequently be  found  in  the  stools,  either  in  cases  of  intestinal  tuberculosis 
or  when  the  sputum  has  been  swallowed  in  pulmonary  disease. 

The  Tuberculin  Reaction. — This  may  be  obtained  in  various  ways: 
(1)  Tuberculin  may  be  injected  subcutaneously  in  a  dosage  of  not  over  0.1 
milligram  (.015  grain)  and  the  occurrence  of  a  constitutional  reaction  with 
rise  of  temperature  noted .  The  procedure  is  valueless  when  fever  is  already 
present,  and  is  not  devoid  of  the  danger  of  rendering  active  a  condition 
which  is  latent.  (2)  The  intracutaneous  test  is  obtained  by  injecting 
0.1  c.c.  (1.6  minim)  of  a  1  :  100  solution  of  old-tuberculin  into  the  super- 
ficial layers  of  the  skin.  The  resulting  appearances  in  positive  cases  are 
very  similar  to  those  seen  in  the  cutaneous  test.  (3)  The  cutaneous 
reaction  of  v.  Pirquet^  presently  to  be  described.  (4)  The  percutaneous 
test,  devised  by  Moro,^  consists  in  vigorous  rubbing,  lasting  1  minute, 
into  the  sound  skin  of  a  50  per  cent,  mixture  of  tuberculin  and  lanolin.  In 
24  to  48  hours  red  papules  appear  varying  in  number  with  the  intensity  of 
the  reaction.  (5)  The  ophthalmo-reaction  of  Wolff-Eisner^  and  Calmette* 
is  obtained  by  dropping  into  the  eye  1  drop  (0.062)  of  a  0.5  per  cent, 
aqueous  solution  of  old  tuberculin.  The  reaction  varies  from  a  slight  red- 
dening up  to  decided  conjunctivitis.  Owing  to  the  damage  to  the  eye 
sometimes  produced,  the  test  has  with  reason  lost  favor. 

The  greater  convenience  and  equal  effectiveness  of  the  cutaneous 
reaction  makes  it  easily  the  choice  of  methods.  It  is  made  by  washing  the 
skin  of  the  upper  arm  with  ether  or  alcohol,  applying  a  drop  of  undiluted 
old-tuberculin,  and  then  scarifying  slightly  through  this  with  a  sterilized 
needle  or  the  special  drill-shaped  scarificator  made  for  the  purpose.  A 
control  scarification  should  be  made  a  couple  of  inches  distant  for  the 
purpose  of  comparison.  A  positive  reaction  develops  within  24  hours, 
sometimes  longer,  and  consists  of  a  red,  slightly  indurated  maculo-papule 
5  mm.  (0.2  inch)  or  more  in  diameter  (Fig.  182).  It  reaches  its  height 
usually  upon  the  2d  day  and  fades  slowly,  often  leaving  slight  scaliness. 
A  papule  of  smaller  size  than  5  mm.  is  not  to  be  considered  certainly 
positive  (von  Pirquet).^     If  the  reaction  obtained  is  doubtful  or  negative, 

1  Wien.  mod.  Woch.,  1907,  LVII,  1370. 

2  Wien.  klin.  Woch.,  1907,  XX,  933. 

3  Berl.  klin.  Woch.,  1907,  XLIV,  7. 

^  Comp.  rend.  acad.  sci.,  1907,  CXLIV,  1324. 
5  Peer's  Lehrb.  der  Kinderh.,  1914,  677. 


Fkj  1H2. — Thk  Vom  Pirqi  et  Ci'taneou.s  TirBEHctLiN  Reaction. 

Child  with  incipient  puhnonjiry  tulxTc-ulosis;  a   +  reaction.     Tiic  control  scarification  is 
barely   to  be  seen,  and  is  inidwaj-  between   the  tnberculin  reactions.      (Kolmvr,  A  Practical 

Tijct-htiiik  of  I iif(  clion,  Imiiniiillii  (iiid  S/irriJic  Tin  rdpi/,  1!(17.) 


TUBERCULOSIS  561 

a  second  trial  may  be  made  in  a  few  days  or,  still  better,  the  intracutan- 
eous test  may  be  used. 

Value  of  the  Tuberculin  Reaction. — Under  ordinary  circumstances  it  is 
fair  to  assume  that  a  negative  tuberculin  reaction,  especially  if  it  is  still 
so  on  the  second  trial,  excludes  the  presence  of  tuberculous  infection  in 
the  patient.  In  patients  gravely  ill  in  an  advanced  stage  of  the  disease, 
the  organism  may  be  so  unable  to  produce  antibodies  that  no  reaction  takes 
place.  Cases  of  general  miliary  tuberculosis  and  of  tuberculous  meningitis 
may  also  fail  to  respond  to  the  test.  There  is  often,  too,  observed  an 
inhibitory  action  of  some  of  the  acute  infectious  diseases,  notably  measles, 
the  tuberculin  reaction  failing  to  develop  during  their  course,  although 
positive  before  or  after  this. 

A  positive  reaction  indicates  that  the  patient  has  or  has  had  tuber- 
culosis, and  that  antibodies  exist  in  the  blood.  The  lesion  may  be  small, 
old,  healed,  and  entirely  unimportant,  and  this  should  always  be  borne 
in  mind  in  forming  a  diagnosis  of  the  nature  of  the  symptoms  present. 
Its  lack  of  value  for  diagnostic  and  prognostic  purposes  increases  in  pro- 
portion as  the  patient  is  older.  In  infancy  the  finding  of  a  positive 
tubercular  reaction  generally  indicates  an  active  process,  and  that  very 
probably  the  symptoms  observed  are  closely  connected  with  this.  This 
is  especially  true  in  the  1st  year  of  life.  It  is  then  of  serious  import, 
although  not  a  certain  proof  that  the  disease  is  advancing  and  that  the 
issue  will  be  fatal.  The  great  frequency  of  the  positive  reaction  in  older 
children,  to  which  reference  has  already  been  made  (p.  539),  shows  how 
guarded  one  must  be  in  attributing  too  much  importance  to  it,  so  far  as 
association  with  the  existing  symptoms  is  concerned. 

In  this  connection  it  is  interesting  to  consider  the  susceptibility  to  the 
tuberculin-reaction  of  those  who  exhibit  the  human  or  the  bovine  type 
of  bacillus  respectively.  Although  a  small  percentage  of  individuals  will 
react  with  the  tuberculin  of  only  one  of  the  two  types  of  the  bacillus, 
the  large  majority  of  those  who  give  a  positive  reaction  with  one  type  will 
do  so  with  the  other  also.  (See  contributions  by  Ramsey,^  Cattaneo,^ 
and  DeLange.^) 

Treatment.  Prophylaxis. — The  great  need  is  that  the  infant  be 
guarded  against  every  possible  contact  with  tuberculous  subjects,  even 
though  these  be  the  parents.  No  nurse  with  tuberculosis,  healed  or 
otherwise,  should  be  employed.  Dwellings  should  be  thoroughly  dis- 
infected if  the  slightest  suspicion  exists  of  the  presence  of  bacilli  in  them. 
The  ingestion  of  milk  from  cows  with  tuberculosis  is  to  be  avoided,  and 
when  it  cannot  be  made  certain  by  veterinary  inspection  that  the  milk 
is  above  suspicion,  it  should  invariably  be  pasteurized.  The  putting  of 
toys  and  the  like  into  the  mouth  of  the  infant  must  be  prevented  as  far  as 
possible,  and  the  greatest  cleanliness  exercised  in  the  care  of  its  finger- 
nails, and  of  the  spoons,  cups,  rubber  nipples,  and  other  articles  used  in 
the  giving  of  food.  Promiscuous  kissing  of  the  baby  by  visitors  is  unwise. 
Association  of  an  infant  in  its  1st  year  with  an  individual  suffering  from 
cough  may  be  dangerous.  In  fact,  during  this  period  the  baby  is  better 
from  every  point  of  view  if  kept  from  such  contact  with  other  individuals. 
When  for  any  reason,  as  among  the  poor,  it  is  impossible  entirely  to  pre- 
vent contact  of  the  infant  with  members  of  the  household  suffering  from 
pulmonary  tuberculosis,  at  least  the  greatest  care  in  the  collection  and 

1  Amer.  Jour.  Dis.  Child.,  1915,  X,  201. 

2  Zeit.  f.  Kinderh.,  Orig.,  1913,  VI,  506. 

3  Nederl.  Tijdschr.  v.  Geneesk.,  1914,  LVIII,  2,  438. 
36 


562  THE  DISEASES  OF  CHILDREN 

destruction  of  the  sputum  can  be  urged.  The  resisting  power  of  the  child 
must  be  maintained  by  abundant,  suitable  nourishment,  life  in  the  open 
air,  plenty  of  sunshine,  gymnastic  exercises,  cool  bathing,  suitable  cloth- 
ing and  other  hygienic  measures.  In  this  line  is  a  temporary  sojourn  at 
the  seashore  or  mountains  if  signs  of  debility  become  manifest.  There  is 
also  great  need  in  the  case  of  delicate  children  for  the  prompt  treatment 
of  bronchitis,  the  removal  of  hypertrophied  tonsillar  tissue,  and  the 
avoidance  of  contact  with  pertussis,  grippe  and  measles.  In  the  produc- 
tion of  immunity  by  tuberculin  nothing  of  real  value  has  as  yet  been 
accomplished.  The  employment  of  vaccines  may  perhaps  later  become 
of  service  both  as  a  preventive  and  as  a  curative  measure. 

Treatment  of  the  Attack. — This  depends  so  greatly  upon  the  localiza- 
tion and  on  other  factors,  that  it  can  be  considered,  for  the  most  part, 
only  in  the  separate  sections  treating  of  the  various  forms  of  the  disease. 
During  the  acute  febrile  stage  the  patient  should  be  much  of  the  time 
at  rest,  but  this  should  be,  if  possible,  in  the  open  air.  Here  may  be 
mentioned  also  the  benefit  in  all  forms  of  tuberculosis  to  be  derived  from 
abundant  nourishment,  especially  milk  in  some  form,  and  from  change 
of  climate,  particularly  to  elevated,  dry  regions,  although  the  seacoast 
is  of  value  in  many  cases.  Treatment  in  sanatoria  for  children,  situated 
in  a  favorable  climate,  is  often  efficacious.  Even  where  change  of  climate 
cannot  be  obtained,  efforts  can  be  made  to  ensure  a  life  largely  in  the 
open  air,  as  by  the  making  use  in  chronic  cases  of  open-air  schools,  and 
the  like,  or  of  similar  methods  employed  at  home  (Knopf), ^  (Michael). ^ 
The  employment  of  tuberculin  of  various  sorts  as  a  curative  agent,  of 
which  so  much  was  once  hoped,  has  not  obtained  any  settled  place  in 
the  treatment  of  the  disease,  especially  in  children.  It  is  but  fair  to 
state  that  it  is  highly  recommended  by  physicians  of  experience;  as  by 
Wittich,^  Schlossmann,^  Beck^  and  others.  There  would  appear  to  be 
always  danger  of  increasing  the  activity  of  the  process,  or  of  awaken- 
ing it  if  it  has  been  dormant.  The  initial  dose  recommended  should  be 
very  small;  not  over  0.001  milligram  (0.00015  grain).  Among  drugs 
probably  the  most  useful  is  cod-liver  oil,  alone  or  combined  with  iodide  of 
iron,  creosote,  or  sometimes  arsenic.  If  it  is  not  well  tolerated  and 
diminishes  the  appetite,  it  should  be  abandoned. 


CHAPTER  XX 
SYPHILIS 


This  affection,  the  origin  of  which  is  unknown,  but  which  in  all  prob- 
ability existed  in  ancient  times,  became  pandemic  in  Europe  toward 
the  end  of  the  15th  century.  In  early  life  it  is  represented  by  two 
forms,  (A)  Acquired  Syphilis;  (B)  Hereditary  Syphilis. 

Frequency. — The  influence  of  the  disease  is  very  great.  It  is  true 
that  Fruhinsholz^  recorded  it  in  but  186  (1.07  per  cent.)  of  17,282  chil- 
dren under  the  age  of  12  years,  only  12  of  these  being  proven  to  be  ac- 
quired syphilis;  and  StilP  found  hereditary  syphilis  in  but  29  (0.6  per  cent.) 

1  Med.  Rec,  1913,  LXXXIV,  87.5. 

2  Review  in  Amer.  Journ.  Dis.  Child.,  1916,  XI,  162. 
=>  Jahrb.  f.  Kinderh.,  1912,  LXXV,  166. 

4  Deut.  med.  Woch..  1909,  XXXV,  289. 
6  Zeit.  f.  Kinderh.,  Orig.,  1913,  VI,  439. 
«  Rev.  d'hyg.  et  de  med.  inf.,  1903,  II,  1. 
^  Pediatrics,  1904,  XVI,  577. 


SYPHILIS  563 

of  4830  children  under  10  years  of  age.  The  statistics  of  Neumann  and 
Oberwarth^  on  69,221  children  and  of  Cassel^  upon  17,448  infants  give  a 
percentage  very  close  to  that  of  Fruhinsholz.  If  the  diagnosis  based 
solely  upon  the  existence  of  a  positive  Wassermann  reaction  be  included 
with  those  determined  by  clinical  examination,  the  proportion  of  instances 
of  hereditary  syphilis  is  increased  decidedly,  ranging  from  2  to  14  per 
cent,  according  to  the  various  statistics  collected  by  Churchill  and 
Austin;^  or,  in  the  United  States,  from  2  to  6  per  cent.  Yet  these  figures 
by  no  means  represent  the  actual  number  of  cases,  since  they  take  no  ac- 
count'of  the  numerous  syphilitic  infants  who  are  born  dead,  prematurely 
or  at  term,  or  who  die  soon  after  birth,  to  say  nothing  of  the  very  large 
number  of  abortions  due  to  this  disease. 

Germ. — Of  both  forms  the  cause  is  the  same:  evidently  a  germ  of 
some  sort,  since  the  disease  is  eminently  infectious.  Various  germs  have 
been  described,  prominent  among  them  being  the  bacillus  of  Lustgarten,^ 
and  the  cytoryctes  hits  described  by  Siegel.^  The  researches  of  Schau- 
dinn  and  Hoffmann^  confirmed  by  many  others,  showed  that  the  cause  is 
a  spirillum,  the  spirochcete  pallida,  or  treponema  pallidum,  which  is  found 
in  the  primary  lesions  and  mucous  patches,  and  in  hereditary  cases  in 
the  various  tissues  and  secretions  of  the  body  also,  especially  the  liver. 

The  etiology  in  general,  the  pathological  anatomy,  and  the  symptoms 
of  the  two  varieties  of  the  disease  will  be  considered  separately. 

(A)  ACQUIRED  SYPHILIS 

Etiology. — This  form  is  much  more  uncommon  than  the  hereditary 
variety  in  early  life,  and  yet  not  infrequently  encountered.  Infection 
takes  place  as  in  adults,  except  that  it  is  usually  by  other  paths  than  the 
genital  tract.  Kissing  by  a  syphilitic  mother  or  wet-nurse;  nursing  from 
a  breast  which  is  the  seat  of  a  syphilitic  lesion;  contact  with  infected 
clothing,  drinking  cups,  nursing  bottles,  and  the  like,  are  the  most 
frequent  methods.  Whether  the  disease  can  be  transmitted  by  the  milk 
itself  of  a  syphilitic  wet-nurse  is  doubtful.  It  has  been  communicated 
by  vaccination  in  the  days  when  human  virus  was  employed,  and 
from  the  mouth  or  instruments  of  a  syphilitic  operator  performing  ritual 
circumcision.  Infection  from  the  genitals  of  the  mother  during  birth  is 
possible  but  infrequent.  Prof  eta's  law — that  an  apparently  healthy  child 
will  not  acquire  syphilis  through  kisses  given  by  its  syphilitic  mother,  or 
through  nursing  from  or  other  contact  with  her — indicates  only  that  the 
infant  has  acquired  a.  certain  degree  of  apparent  immunity,  because  it  is, 
in  fact,  already  really  syphilitic. 

Pathological  Anatomy  and  Symptoms. — These  do  not  differ 
materially  from  those  characteristic  of  adult  life,  age  appearing  to  have 
no  influence.  There  is  an  initial  lesion  at  the  point  of  infection,  followed 
in  due  course  by  the  usual  secondary  and  finally  tertiary  manifestations. 
The  attack  is  usually  milder  than  in  adults,  and  less  severe  than  heredi- 
tary syphilis;  widespread  cutaneous  eruption  is  not  uncommon.  i>ut  is 
more  macular  than  papular;  and  there  is  a  marked  disposition  in 
children  to  the  development  of  moist  condylomata. 

1  Arch.  f.  Kinderh.,  1905,  XIJI,  64. 

2  Arch.  f.  Kinderh..  1909,  J.,  154. 

3  Amer.  .lour.  Di.s.  Child.,  19Ui.  XII,  355. 

*  Wien.  med.  Woch.,  18S4,  X.WIV,  1389. 

*  Miinch.  med.  Woch.,  1905,  LII,  1321. 

"  Arbeiten  aus  d.  kais.  Gesundheitsamt,  1902,  XXII,  527. 


564  THE  DISEASES  OF  CHILDREN 

(B)  HEREDITARY  SYPHILIS 

Etiology. — Of  all  infectious  diseases  this  is  the  most  frequently 
inherited.  It  may  be  transmitted  by  either  parent  or  by  both,  but  in 
the  large  majority  of  cases  the  father  is  the  original  source  of  the  disease. 
The  mother,  already  syphilitic  at  the  time  of  conception,  may  infect  the 
fetus,  the  father  being  healthy.  Much  less  often  the  mother  may  acquire 
syphilis  at  some  period  during  pregnancy,  and  then  transmit  it  to  the 
fetus  (post-conceptional  syphilis).  Whether  the  syphilitic  father  can 
communicate  it  to  the  fetus  without  infection  of  the  mother  has  been 
disputed.  It  is  certainly  of  very  common  occurrence,  so  far  as  any  ordi- 
nary evidence  of  maternal  syphilis  is  concerned  either  at  the  time  of  par- 
turition or  later  in  life;  yet  Colles'  law,^  that  the  mother  of  a  syphilitic 
infant  will  not  become  infected  by  contact  with  it,  even  though  it  have 
lesions  in  the  mouth,  shows  that  she  has  in  some  way  become  immune; 
and  it  seems  very  probable  that  this  is  because  she  is,  herself,  a  subject 
of  the  disease,  in  a  modified  form  and  without  symptoms.  The  investi- 
gations of  Knopfelmacher  and  Lehndorf^  with  Wassermann's  comple- 
ment-fixation test,  confirmed  by  many  others,  show  that  such  mothers  do, 
in  fact,  give  the  characteristic  reaction  for  syphilis  in  a  large  proportion  of 
cases.  If  this  point  of  view  be  accepted,  then  there  is  no  such  thing  as 
the  infection  of  the  ovum  by  spore-carrying  semen.  On  the  contrary, 
the  virus  infects  the  mother,  the  placenta  becomes  syphilitic,  and  the 
organisms  are  thus  allowed  to  pass  through  it  to  the  blood  of  the  fetus. 
Transmission  of  the  disease  to  the  fetus  is,  therefore,  always  from  the 
mother. 

Whether  or  not  the  infant  of  distinctly  syphilitic  parents  will  be  born 
syphilitic  depends  upon  various  factors.  When  both  parents  are  syphi- 
litic the  offspring  will  almost  always  be  infected.  The  stage  of  the  dis- 
ease is  important.  If  secondary  symptoms  are  present  in  either  parent, 
transmission  is  almost  certain.  If  the  symptoms  in  the  parents  have  been 
overcome  by  treatment  before  the  time  of  conception,  or  if  they  are  terti- 
ary, transmission  will  probably  not  occur,  but  to  this  there  are  numerous 
exceptions.  In  general,  the  more  recent  the  disease  in  either  parent, 
the  more  certain  is  it  likely  to  appear  in  the  child  and  the  more  severe 
are  the  symptoms.  As  regards  post-conceptional  syphilis,  the  shorter 
the  time  between  infection  and  parturition,  the  less  liable  is  the  fetus  to 
be  syphilitic.  In  early  post-conceptional  infection  of  the  mother  active 
treatment  may  prevent  the  transmission  of  syphilis  to  the  fetus.  There 
is  no  satisfactory  proof  of  the  transmission  of  the  disease  to  the  third 
generation. 

Pathological  Anatomy. — In  cases  of  early  abortion  there  are 
often  no  characteristic  microscopical  anatomical  changes  whatever  found 
in  the  fetus.  In  62  such  cases  examined  by  Hecker-^  gross  lesions  were 
discovered  in  only  15 ;  i.e.  24  per  cent.,  and  lesions  shown  only  by  the  micro- 
scope in  an  equal  number.  On  the  other  hand,  in  the  fetus  approaching 
full  term,  and  in  infants  dying  a  few  days  after  birth,  the  changes  are 
very  characteristic.  In  children  not  showing  symptoms  of  syphilis  at 
birth,  but  dying  of  it  after  a  few  weeks  or  months,  if  often  happens  that 
few,  if  any,  pathological  changes  of  the  internal  organs  are  discovered. 
The  longer  the  time  after  birth  before  symptoms  appear  the  less  liable 
are  the  internal  organs  to  be  found  diseased.     The  basis  of  the  early 

^  Pract.  Observ.  on  Vener.  Dis.  and  the  Use  of  Mercury,  London,  1837. 

2  Monatssch.  f.  Kinderheilk.,  1909,  VIII,  34. 

3  Jahrb.  f.  Kinderheilk.,  1901,  LIV,  685. 


SYPHILIS  565 

alterations  is  a  diffuse  cellular  proliferation  arising  from  the  perivascular 
connective  tissue  with  involvement  of  the  vessels.  With  this  there  is  an 
interference  with  the  development  of  the  organs.  Only  later  is  there  a 
tendency  to  the  production  of  isolated  gummata. 

The  most  constantly  present  and  characteristic  pathological  changes 
in  fetal  syphilis  are  those  of  the  osseous  system,  especially  the  long 
tubular  bones  and  the  ribs.  In  the  fetus  and  in  j^oung  infants  the  lesion 
is  usually  an  osteochondritis.  Acquired  syphilis  does  not  exhibit  this 
alteration.  It  occurs  oftenest  in  the  epiphyses  of  the  long  bones  of  the 
legs  and  arms  (Epiphysitis).  There  is  a  widening  of  the  cartilaginous 
layer  through  multiplication  of  the  cells,  with  hardening  due  to  abnormal 
calcification  and,  later,  a  softening  from  cellular  infiltration,  exuberant 
granulation-tissue,  and  necrosis  with  consecutive  separation  of  the  epi- 
physis. Sometimes  suppuration  occurs  as  a  result  of  a  mixed  infection. 
Dactylitis  is  a  lesion  sometimes  observed,  especially  in  early  childhood. 
In  later  childhood  osteochondritis  is  not  often  seen,  but  there  is  found  an 
osteoperiostitis,  particularly  of  the  skull  and  of  the  bones  of  the  forearms 
and  legs.  This  may  be  diffuse  and  hyperplastic,  or  it  may  be  represented 
by  isolated  gummata,  especially  on  the  cranium.  Involvement  of  the 
joints  also  occurs  in  the  form  of  synovitis  or  chondroarthritis. 

Enlargement  of  the  spleen  is  nearly  always  present  in  the  fetus  or  the 
new  born.  It  exhibits  merely  h^^perplasia  but  nothing  characteristic. 
At  a  later  period  is  observed  an  enlargement  dependent  upon  interstitial 
changes  or,  less  frequently,  gummata.  Changes  in  the  liver  are  observed 
in  the  fetus  and  the  new  born  about  as  frequently  as  those  of  the  spleen. 
The  organ  is  enlarged,  firm,  hard  and  irregular,  with  the  capsule  thickened. 
On  section  it  is  of  yellowish  color,  sometimes  with  numerous  whitish, 
miliary  nodules  consisting  of  minute  gummata.  There  is  also  decided 
increase  of  the  interstitial  connective  tissue,  with  consequent  atrophy  of 
many  of  the  hepatic  cells,  and  narrowing  of  the  branches  of  the  blood- 
vessels and  small  biliary  passages.  The  process  ma^^  be  diffuse,  or 
limited  to  certain  areas.  After  early  childhood  the  liver  less  often  ex- 
hibits alterations,  although  gummata  of  considerable  size  are  sometimes 
found.  The  alimentary  canal  may  exhibit  condylomata  of  the  tongue, 
and  the  same  lesion  or  chronic  inflammation  or  ulceration  of  the  pharynx 
and  tonsils.  Cellular  infiltration  and  interference  with  parenchymatous 
development  may  occur  in  the  stomach  and  intestines. 

A  catarrhal  inflammation  of  the  nose  is  very  frequent,  and  ulcerative 
lesions,  superficial  or  deep,  are  often  observed  in  the  later  stages  of  the 
disease.  Perichondritis  or  ulceration  of  the  larynx  is  sometimes  seen, 
and  exceptionally  gummata  may  form  in  the  trachea  or  bronchi  and  ter- 
minate in  stenosis.  In  the  fetus  and  in  infants  dying  soon  after  birth 
there  is  often  present  the  so-called  "white  hepatization"  of  the  lung.  In 
this  a  considerable  portion  of  the  pulmonary  tissue  appears  whitish-grey, 
airless,  and  smooth  on  section,  due  to  filling  of  the  alveoli  with  dogcncrated 
epithelium,  thickening  of  their  walls,  and  increase  of  the  interstitial 
connective  tissue.  Changes  at  later  periods  of  the  disease  are  less  com- 
mon, and  consist  of  gummatous  deposits  or  extensive  interstitial  infla- 
mmation. Lesions  of  the  heart  are  not  uncommon,  and  gummata  and 
interstitial  myocarditis  have  been  seen  even  in  infancy.  The  nervous 
system  is  not  freciuently  involved.  (Jummata  nvv  only  rarely  seen  in  the 
brain  and  spinal  cord,  and  chronic  meningitis,  chiefly  l)asilar,  is  sometimes 
met  with;  Init  the  most  frequent  lesion,  especially  in  infancy  is,  hydro- 
cephalus. 


566  THE  DISEASES  OF  CHILDREN 

The  genito-urinary  system  exhibits  chronic  interstitial  nephritis, 
occasionally  even  in  infancy.  In  the  fetus  and  new-born  enlargement 
of  the  kidney  and  parenchymatous  changes  are  common.  Gummata  of 
the  kidney  are  exceptional  in  early  life.  The  testicle  may  be  enlarged 
as  the  result  of  interstitial  inflammation,  and  gummata  are  sometimes 
found.  Chronic  suppurative  otitis  is  a  frequent  result  of  syphilitic 
pharyngitis.  The  eyes  are  less  often  involved  in  early  life;  choroiditis 
and  optic  neuritis  sometimes  occurring;  and  iritis  developing  even  during 
intrauterine  life.  Keratitis  is  common  among  the  later  lesions.  Mul- 
tiple enlargement  of  the  lymphatic  glands  is  seen,  especially  in  the  groin, 
axilla,  neck  and  about  the  elbow.  The  pancreas,  thymus  gland,  peri- 
toneum, suprarenal  bodies  and  thyroid  gland  occasionally  exhibit 
gummata,  interstitial  inflammation,  or  other  syphilitic  manifestations. 
Small  cystic  formations  are  frequently  found  in  the  thymus  gland. 
Lesions  of  the  skin  are  described  under  symptoms. 

Symptoms.- — ^It  is  convenient  to  divide  the  symptoms  of  hereditary 
syphilis  into  I.  The  Early  Manifestations;  and  II.  Later  Manifesta- 
tions. 

I.  The  Early  Manifestations  of  Hereditary  Syphilis. — Mothers 
with  recent  syphilitic  infection,  contracted  at  or  near  the  time  of  concep- 
tion, very  commonly  abort  and  the  accident  is  likely  to  be  repeated  in  later 
pregnancies.  The  lesions  found  in  the  fetus,  born  dead,  have  already 
been  described.  (See  Pathological  Anatomy.)  Other  infants  are  still- 
born at  term.  Some  are  born  alive  but  with  evidences  of  severe  infection, 
and  are  usually  capable  of  living  only  a  few  days  or  weeks.  They  are 
feeble,  wasted,  atrophic,  and  exhibit  all  the  symptoms  of  extreme  ina- 
nition. There  may  be  present  at  birth  coryza  and  a  pemphigoid  erup- 
tion of  the  skin,  especially  on  the  soles  and  palms,  but  sometimes  else- 
where. Enlargement  of  the  liver  and  spleen  are  demonstrable.  The 
skin  about  the  mouth  exhibits  fissures,  and  excoriations  are  present  on 
the  buttocks.  Still  other  infants,  although  feeble  and  poorly  devel- 
oped and  with  enlargement  of  the  liver  and  spleen  do  not  at  first  exhibit 
the  group  of  symptoms  characteristic  of  syphilis,  but  after  a  few  days 
rapidly  develop  them,  the  atrophy  and  inanition  being  prominent  fea- 
tures from  the  moment  of  birth.  The  large  majority  of  syphilitic  in- 
fants, however,  appear  healthy  and  well  developed  at  birth  and  symptoms 
appear  only  after  an  interval  (infantile  syphilis).  A  general  estimate 
by  Miller^  based  upon  his  own  observations  with  those  of  Zeissl  and  Kasso- 
witz  would  make  from  50  to  65  per  cent,  of  the  cases  first  show  symptoms 
in  the  1st  month,  chiefly  in  the  3d  and  4th  weeks;  from  20  to  30  per  cent, 
in  the  2d  month,  and  nearly  all  of  the  remaining  10  to  15  per  cent,  in 
the  3d  month.  Generally  the  danger  of  syphilis  appearing  is  over  after 
3  months  but  to  this  there  are  exceptions,  and  the  first  symptoms  may 
occasionally  not  develop  until  the  4th  month  or  even  later. 

The  earliest  symptom  in  the  child  apparently  healthy  at  birth  is 
usually  a  persistent  coryza,  producing  the  "snuffles"  often  described. 
This  is  soon  followed  by  a  hoarse,  high-pitched  and  very  persistent  crying 
especially  at  night.  In  a  short  time  cutaneous  manifestations  appear, 
often  accompanied  by  slight  fever;  and  then,  or  earlier,  evidences  of 
osseous  lesions  with  consequent  apparently  paralytic  conditions.  Some- 
times the  symptoms  mentioned  are  little,  if  at  all,  marked,  and  severe 
visceral  affections  are  more  prominent  and  often  lead  to  a  fatal  ending. 
As  a  rule,   however,  decided  visceral  symptoms  are  characteristic  of 

1  Jahrb.  f.  Kinderheilk.,  1888,  XXVII,  362. 


SYPHILIS  567 

fetal  syphilis,  and  the  earlier  they  manifest  themselves  in  the  new  born 
the  worse  the  general  symptoms  are  liable  to  be.  The  majority  of 
infants  who  are  in  good  condition  at  birth  and  exhibit  no  syphilitic 
manifestations  of  any  sort  for  some  weeks,  will  present  no  visceral  symp- 
toms of  any  moment. 

The  promptness  of  development  and  the  severity  of  the  symptoms  are, 
in  general,  proportionate  to  the  intensity  of  the  infection.  In  severe 
cases  increasing  debility  and  wasting  begin  early  and  advance  as  the 
disease  progresses,  and  infants  may  finally  exhibit  all  the  evidences  of 
extreme  marasmus.  In  milder  cases  the  general  health  and  nutrition 
may  remain  unaffected. 

The  symptoms  referred  to,  as  well  as  others  which  develop,  require 
more  detailed  description : — 

,^  Cutaneous  Symptoms. — The  severest  symptom  of  this  nature,  which 
has  been  designated  pemphigus  syphiliticus  neonatorum,  is  a  bullous 


4  -         ^'^. 


Fig,  183. — Hkreditary  Syphilis,  Bullous  Eruption  on  Soles  of  Feet. 
Courtesy  of  Dr.  J.  F.  Schamberg. 

eruption,  with  bloody  or  purulent  contents,  oftenest  found  on  the  palms 
and  soles,  but  at  times  widespread  and  causing  extensive  exfoliation 
of  the  skin  (Fig.  183).  Most  instances  show  the  lesion  at  birth  and 
the  cases  generally  terminate  fatally.  In  milder  cases  of  syphilis  there 
is  no  cutaneous  eruption  at  first  and  the  earliest  evidence  of  it  in  any 
form  appears  generally  about  a  week  after  the  development  of  the  coryza. 
The  eruption  may  be  circumscribed  or  diffuse.  The  cir  cunt  scribed  form 
is  much  tlie  same  as  that  found  in  acquired  syphilis.  It  is  oftenest 
maculo-papular,  and  occurs  in  the  shape  of  small,  slightly  elevated, 
pea-sized  or  larger  macules  associated  with  papules  more  or  less  numerous, 
situated  especially  upon  the  lower  extremities,  the  face,  scalp,  neck, 
and  flexor  surfaces  of  the  upper  extremities,  the  palms  and  soles.  Scaling 
may  be  present  upon  the  surface.  It  is  unattended  by  itching  and 
varies  in  color  from  coppery-red  to  brown  or  yellowish  according  to  the 
age  of  the  lesion.  Alisorption  may  take  place  in  the  center,  i)roducing 
in  some  cases  a  well-ninrkcd  annular  appearance  (Fig.  184).  In  certain 
regions  there  may  develop  fhitt(MUHl  elevations  with  moist  surfaces — 
the  "moist  condyloma"  or  mucous  patcli.     These  are  commonest  about 


568 


THE  DISEASES  OF  CHILDREN 


Fig.   lb>4. — Hereditary  Syphilis,  Maculo-papular  Eruption. 
Unusual  degree  of  annular  appearance.      Courtesy  of  Dr.  J.  F.  Schamberg. 


Fig.   185. — Papulo-pustular  Syphiloderm. 
Courtesy  of  Dr.  M.  B.  Hartzell. 


SYPHILIS 


569 


the  mouth,  the  anal  region  and  the  genitals,  but  may  develop  in  any 
situation  where  the  skin  is  thin  and  delicate,  such  as  behind  the  ears, 
between  the  fingers  and  about  the  navel.  The  condyloma,  however, 
is  not  the  earliest  eruption  of  hereditary  sj^philis,  but  is  particularly 
characteristic  of  relapses.  A  more  papular  eruption  of  a  brown-red  color 
is  seen  oftenest  upon  the  palms  and  soles  and  the  forehead.  Less  often 
seen,  and  in  severer  cases,  is  a  papulo-pustular  eruption  (Fig.  185)  which 
may  terminate  in  ulcerated  or  ecthymatous  lesions.  The  roseola  of 
acquired  syphilis  is  rarely  if  ever  witnessed  in  the  hereditary  form. 

The  diffuse  eruption  is  common  and  very  characteristic,  and  is  not 
observed  in  acquired  syphilis.     It  consists  of  a  diffuse  infiltration  of  the 


Fig.     IMi. Svj'HILriir     Si    ALI\(.     i>l       I'l.l.  I'. 

From  an  infant  aged  6  weeks,  in  the  Children's  Medical  Ward  of  the  Hospital  of  the  Uni- 
versity of  Pennsylvania.  At  the  age  of  2  weeks  snuffles  and  cutaneous  eruption  developed. 
The  latter  seen  as  macules  on  the  face  and  limbs  and  as  a  red  diffuse  infiltration  on  the 
soles  of  the  feet.     The  illustration  shows  the  typical  scaly  appearance  following. 


skin,  situated  usually. on  the  palms  and  soles,  face,  scalp,  genital  and  anal 
regions,  and  the  flexor  surfaces  of  the  thighs.  It  presents  a  somewhat 
shining  surface  of  a  copper-red  or  brownish-yellow  color  and  renders  the 
skin  distinctly  stiffened.  Slight  desquamation  is  often  present.  In 
other  cases  it  produces  extensive  desquamation  in  small  scales  or  larger 
flakes  (Fig.  186).  Sometimes  when  inflamed  it  suggests  the  appearance 
of  eczema,  with  formation  of  crusts  but  differs  in  the  presence  of  stiffness 
of  the  skin  and  the  absence  of  the  intensely  red  color  of  the  latter  disease. 

Fissures  in  the  skin  are  very  characteristic  early  symptoms.  They 
occur  especially  about  the  mouth  and  eyelids  at,  the  ahrof  tlie  nose,  and 
at  the  anus.  Those  about  the  mouth  are  situated  on  the  lips,  and  extend 
a  short  distance  into  the  skin  beyond.  They  are  often  arranged  radially, 
especially  at  the  labial  angh^  (Fig.  187),  are  narrow,  infiltrated,  rather 
deep,  painful,  bleed  readily  and  are  often  covereti  with  crusts.  When 
healed  they  may  leave  very  characteristic  linear  scarring. 

The  nails  are  often  dry,  shriveled,  narrowed  and  curved  in  a  sharp 


570 


THE  DISEASES  OF  CHILDREN 


transverse  curve,  exhibit  transverse  dssures,  and  may  fall  off."*' In  other 
cases  inflammation  about  the  nail  occurs  (syphilitic  paronychia).     There 


Fig.   1S7. — Fissikks  aboit  thk  Mduth  in  Hereditary  Syphilis. 
Female  child,  aged  6  months,  in  the  Children's  Ward  of  the  Hospital  of  the  University 
of  Pennsylvania.      Previous  history  not  discoverable,  except  that  the  child  had  been  ill 
since  its  1st  month.      Under  treatment  for  a  month  with  mercury  and  arsphenamine;  no 
improvement;  death. 


Fig.   188. — Syphilitic  Alopecia. 
Courtesy  of  Dr.  J.  F.  Schamberg. 


may  be  loss  of  hair  from  the  scalp  (Fig.  188),  eyelids  and   eyebrows. 
This  is  present  at  birth  in  fetal  cases. 


SYPHILIS  571 

Mucous  Membranes. — Lesions  of  the  mucous  membranes,  apart 
from  the  rhinitis  to  be  described,  are  not  frequent  early  symptoms  in 
infancy  and  are  usually  not  seen  until  the  infant  is  some  months  old. 
Broad  condylomata  may  develop  on  the  lining  of  the  mouth,  the  tongue 
and  the  vulva,  but  oftener,  as  stated,  upon  the  skin  near  the  muco- 
cutaneous border.  Ulcers,  general  superficial,  may  occur  upon  the 
mucous  membranes  of  the  mouth,  pharynx,  and  elsewhere.  "Snuffling" 
is  generally  the  first  manifestation  of  the  disease,  and  a  very  persistent 
one.  It  is  nearly  always  present,  and  often  at  birth,  and  may  be  the 
only  symptom.  The  nasal  mucous  membrane  is  swollen,  and  respira- 
tion may  be  much  interfered  with,  rendering  sucking  difficult  and  sleep 
disturbed.  Later  there  develops  a  serous,  mucous  or  muco-purulent 
discharge,  often  tinged  with  blood,  and  thick  crusts  block  the  nostrils 
and  interfere  still  further  with  breathing.  The  mouth  may  be  dry  from 
the  constant  mouth-breathing.  Hoarseness  may  attend  the  coryza, 
being  sometimes  one  of  the  earliest  symptoms.  Hemorrhages  occasion- 
ally occur  from  the  mucous  membrane  and  from  some  of  the  cutaneous 
lesions,  or  sometimes  in  the  internal  organs.  Some  of  the  cases  of 
hemorrhagic  disease  in  the  new  born  very  probably  owe  their  origin 
to  syphilis. 

The  lymphatic  glands  may  show  moderate  enlargement,  especially  in 
the  axilla,  elbow,  groins  and  neck.  This  enlargement  of  the  cubital 
glands  is  very  common  and  suggestive,  but  not  proof  of  the  existence  of 
syphilis.  Syphilitic  glands  appear  as  multiple,  hard  bodies,  without 
tendency  to  suppurate.  From  a  study  of  390  children,  Reichenecker,^ 
concludes  that  epitrochlear  adenitis  is  most  frequently  due  to  syphilis, 
and  Gotzky2  believed  that  in  infancy  it  is  almost  certainly  dependent 
upon  this  disease.  It  should,  however,  be  stated  that  these  views  do 
not  meet  universal  acceptance,  and  the  frequency  of  enlargement  of  the 
lymphatic  glands  in  congenital  syphilis  is  probably  over-estimated.  The 
teeth  are  often  late  in  their  eruption  and  decay  early,  but  show  nothing 
characteristic. 

The  osseous  system  (see  also  Vol.  II,  p.  450,  Syphilis  of  the  Bones)  is 
frequently  affected  in  early  life,  the  most  characteristic  symptom  being  an 
osteochondritis.  This  lesion  really  begins  in  fetal  life  and  lasts  a  variable 
time,  although  the  clinical  evidences  of  it  are  usually  not  discoverable 
at  birth.  It  appears  first  as  a  tender  swelling  at  the  junction  of  the  shaft 
and  epiphysis,  oftenest  in  the  extremities,  and  may  advance  to  complete 
separation  of  the  epiphysis  with  temporary  loss  of  power  and  pain  on 
passive  movement,  suggesting  paralysis ; — the  syphilitic  pseudo-paralysis 
described  by  Parrot.^  This  paralytic  condition  occurs  oftenest  in  the 
earlier  months  of  life,  and  usually  in  one  arm,  which  hangs  motionless 
with  the  forearm  in  full  pronation  and  the  palm  of  the  hand  turned  out- 
ward. The  inability  to  move  the  limb  depends  upon  pain,  not  upon  loss 
of  power.  The  process  may  involve  the  joint  itself  with  a  secondary 
suppuration  (Fig.  189),  or  a  large  portion  of  the  shaft  of  the  bone  may 
be  attacked  by  the  disease.  It  is  undetcrminetl  whether  all  the  cases  of 
pseudo-paralysis  depend  in  reality  upon  an  osseous  lesion.  A  foim  of 
osteitis  of  the  bones  of  the  fingers  (dactylitis),  and,  less  often,  of  the  toes, 
has  been  described  by  Hochsinger'*  as  occurring  during  the  early  symp- 

»  Le  nourrisson,  1915,  111,  193.     Ref.  Drit.  Jour.  Child.  Dis.,  1910,  Xlll,  GO. 

2Zcit.  f.  Kindcrh.  Orip;.,  19i:i,  VII,  IVi. 

'  Arch,  de  phys.  norm,  ct  path.,  1871-2,  IV,  319. 

*  Pfauiullcr  and  Sclilossmaim.  HmikII).  d.  Kiiidcrlicilk.  190(i.  I,  2.  91G. 


572 


THE  DISEASES  OF  CHILDREN 


toms  in  infancy.  It  begins  chiefly  in  the  proximal  phalanx,  is  bilateral, 
and  never  advances  to  suppuration.  (See  Syphilitic  Dactylitis,  Vol.  II, 
p.  451,  Fig.  392.)  A  more  destructive  dactylitis  may  develop  at  a  later 
period  in  infancy.     It  is  described  under  the  later  symptoms  of  syphilis. 


Fig.  189.- 


-Syphilitic  Epiphysitis  with  Secondary  Suppuration. 
Same  case  as  Fig.  187. 


Craniotabes  is  an  occasional  osseous  lesion  seen  in  infancy.  It  con- 
sists of  thin,  softened  spots,  particularly  in  the  occipital  region,  but  is  not 
entirely  pathognomonic  of  syphilis  since  it  may  occur  in  rachitis  as  well. 


Fig.   190. — Saddle-nose  in  Early  Syphilis. 
Same  case  as  Fig.  187. 


(See'p.  587 ;  Vol.  II,  p.  428. )  Flattening  of  the  bridge  of  the  nose  producing 
the  "saddle-nose"  is  sometimes  an  early  symptom  (Fig.  190).  It  may  be 
only  an  apparent  flattening  at  this  stage,  but  often  depends  upon  actual 


SYPHILIS  573 

involvement  of  the  cartilages  and  bones.  The  affections  of  the  eye  and 
ear  among  the  early  symptoms  of  syphilis,  already  referred  to  in  discus- 
sing pathological  anatomy,  consist  principally  of  iritis,  choroiditis,  optic 
neuritis  and  purulent  otitis. 

Visceral  lesions  are,  as  indicated,  early  symptoms  more  characteristic 
of  syphilis  of  the  fetus  and  the  new  born  than  of  the  disease  first  showing 
itself  in  infants  past  this  period.  They  date  from  intra-uterine  life  and 
are  well-marked  only  in  unfavorable  cases.  The  commonest  clinical 
manifestation  is  decided  enlargement  of  the  liver,  the  organ  presenting 
a  hard  edge  on  palpation  and  projecting  considerably  farther  downward 
than  normal.  Ascites  and  icterus  occasionally  result.  (See  Congenital 
Obliteration  of  the  Bile  Ducts,  p.  273.)  The  spleen  also  may  be  much 
enlarged.  Symptoms  depending  upon  lesions  of  the  nervous  system  are 
not  very  common  early  manifestations.  Among  them  are  those  of  men- 
ingitis and  the  consequent  hydrocephalus.  This  may  develop  at  the 
time  of  the  early  cutaneous  eruption,  or  later  during  relapses.  A  func- 
tional disturbance  is,  however,  very  frequent ;  namely  the  great  w^akeful- 
ness  with  persistent  crying,  especially  at  night.  This  may  very  probably 
be  due,  at  least  to  some  extent,  to  the  pains  in  the  bones.  Albuminuria 
may  or  may  not  depend  upon  the  existence  of  syphilitic  nephritis.  Ac- 
cording to  Hintzelmann^  evidences  of  nephritis  were  found  in  14  out  of 
41  syphilitic  infants. 

The  general  nutrition  suffers  badly  in  severe  cases.  With  the  develop- 
ment of  other  symptoms  there  is  a  rapid  emaciation  with  marked  anemia, 
the  blood  showing  diminution  of  the  red  cells  and  hemoglobin,  and  in- 
crease of  the  leucocytes.  The  skin  often  exhibits,  besides  the  pallor,  a 
peculiar  cafe-au-lait  color,  either  throughout  or  in  certain  localities,  espe- 
cially the  face.  The  veins  of  the  scalp  are  sometimes  much  dilated.  The 
debility  is  great,  and  a  fatal  ending  may  occur  dependent  upon  a  marantic 
state,  and  entirely  independent  of  any  discoverable  affection  of  the  digest- 
ive apparatus  or  fault  with  the  food.  In  cases  which  recover,  the  anemia 
persists  after  the  disappearance  of  all  other  symptoms.  Sometimes  the 
marasmus  is  the  earliest  or  even  the  only  symptom,  and  not  infrequently 
it  does  not  yield  at  all  to  antisyphilitic  treatment. 

The  frequency  of  the  occurrence  of  the  different  early  symptoms,  ac- 
cording to  the  observations  of  Still, ^  shows  snuffling  70  percent.;  cuta- 
neous eruptions  69  per  cent. ;  splenic  enlargement  45  per  cent.,  and  quite 
decided  in  22  per  cent.;  affections  of  the  eye  15  per  cent.;  laryngitis 
14  per  cent.;  epiphysitis  11  per  cent.;  orchitis  8  per  cent.  Hochsinger^ 
found  enlargement  of  the  liver  in  31  per  cent,  of  the  cases,  always  accom- 
panied by  splenic  enlargement.  , 

II.  Later  Manifestations  of  Hereditary  Syphilis — The  symp- 
toms just  described  would  be  classified  as  secondary  ones  in  the  acquired 
disease,  there  being,  of  course,  no  primary'-  lesion  in  the  inherited  affection. 
They  appear  for  the  most  part  in  the  1st  and  2d  months  of  life,  and  most  or 
all  of  them  disappear  entirely  and  permanently  under  proper  treatment 
in  a  few  weeks.  Unless,  however,  treatment  is  long  continued,  recurrence 
occurs  in  a  few  months,  or  by  the  end  of  the  1st  year  or  later,  exhibiting 
some  of  the  original  cutaneous  and  other  symptoms,  with  a  special  tend- 
ency, however,  in  early  childhood  to  the  development  of  cond3'lomata. 
That  this  may  take  place  in  spite  of  treatment  is  shown  by  the  fact  that 

1  Zeit.  f.  Kinderh.,  OriR.,  1913,  IX,  27. 

2  Lancet,  1904,  II,  1402. 

^  Pfaundler  and  Schlossmann,  Handb.  d.  Ivinderheilk,  1906,  I,  2,  921. 


574 


THE  DISEASES  OF  CHILDREN 


in  208  cases  of  congenital  syphilis  observed  by  Hochsinger^  during  a 
period  of  more  than  4  years,  131  (63  per  cent.)  exhibited  recurrence,  and 
of  these  112  (54  per  cent.)  had  undergone  treatment  carried  out  in  a 
thorough  manner. 

In  addition  to  those  described,  new  symptoms  may  appear  which 
would  be  classified,  for  the  most  part,  as  tertiary  in  acquired  syphilis; 
prominent  among  them  being  gummata  in  various  regions.  These  are 
seen  usually  after  the  period  of  early  childhood.  In  other  cases  the  later 
symptoms  develop  about  the  time  of  puberty  or  even  after  this,  without 
any  of  the  earlier  secondary  sj^mptoms  having  been  observed,  or,  if 
noticed,  so  slight  that  their  nature  was  unrecognized.     To  this  form  of  the 


Fig.   191. — Gummata  of  Elbows  a.nd  Uiii..-iT  i:^'  Lati.  IIekeditary  Syphilis. 
Courtesy  of  Dr.  H.  R.  Wharton. 


disease  is  sometimes  applied  the  title  "Syphilis  hereditaria  tarda."  The 
existence  of  such  a  condition  without  previous  symptoms  has  been  much 
disputed,  as  is,  indeed,  the  proper  application  of  the  name. 

The  principal  later  symptoms  of  syphilis  are  the  affections  of  the 
permanent  teeth  and  of  the  bones,  eyes  and  ears,  and  various  lesions 
of  the  skin,  principally  of  a  condylomatous  or  gummatous  nature.  Some 
of  the  later  symptoms  must  be  described  more  in  detail : — 

The  general  nutrition  suffers,  there  being  a  decided  retardation  of 
growth,  general  impairment  of  vigor,  delayed  puberty,  and  anemia. 
The  last  may  persist  after  other  symptoms  have  disappeared. 

Osseous  changes  are  present,  usually  represented  by  localized  gummata 
or  by  a  hyperplastic  osteoperiostitis.  This  latter  affects  chiefly  the  long 
bones  of  the  extremities,  and  the  cranium.  It  produces  thickening, 
tenderness,  and  pain  which  is  most  marked  at  night.     In  the  tibia,  which 

1  Ergebnisse.  inn.  Med.  u.  Kinderh.,  1910,  V,  84. 


SYPHILIS  575 

is  the  bone  oftenest  involved,  there  is  a  thickening  and  curvature  of  the 
anterior  edge,  resulting  in  the  well-known  sabre-tibia  (Vol.  II,  p.  452,  Fig. 
393).  When  the  cranium  is  attacked  there  results  a  diffuse  thickening  with 
corresponding  deformities  (Fig.  393).  A  dactylitis  affecting  one  or  more 
fingers  and  often  going  on  to  necrosis,  and  in  which  the  soft  parts  are  also  in- 
volved, is  seen  oftener  in  early  childhood  than  at  a  later  period.  It  attacks 
usually  the  proximal  phalanx.  (SeeDactylitis,  Vol.  II,p.451.)  Gummata 
of  the  bones  (Fig.  191)  may  develop  in  various  regions  and  persist  for  a  long 
time;  finally  breaking  down  and  forming  ulcers,  or  being  absorbed  and 
leaving  depressions.  On  the  skull,  especially  the  parietal  and  frontal 
regions,  they  form  large  nodular  masses.  These  or  the  osteoperiostitis 
referred  to  produce  decided  alterations  in  the  shape  of  the  head — the 
"keel-shaped"  cranium,  with  central  frontal  deposit,  and  the  "natiform" 
cranium,  with  bilateral  parietal  deposits.  Hochsinger^  considers  these  as 
more  commonly  early  symptoms.     A  frequent  site  of  gummata  in  child- 


FiG.  192. — Saddle-nose  in  Later  Hereditary  Syphilis. 
Courtesy  of  Dr.  Harry  Lowenburg. 

hood  is  the  nasal  septum  and  hard  palate,  in  both  of  which  localities 
breaking  down  is  liable  to  occur.  The  loss  of  tissue  is  sometimes  wide- 
spread and  the  palate  may  be  perforated  or  much  of  the  nose  destroyed. 
The  saddle-nose,  described  as  an  occasional  early  symptom,  may  develop 
in  childhood  also,  as  the  result  of  destructive  necrosis  in  the  bone  and 
cartilage  (Fig.  192).  A  swelling  of  the  knee-joints  is  a  not  uncommon 
distinctly  later  symptom.  It  is  bilateral  and  may  be  either  a  hydrarthro- 
sis (Fig.  193)  or  a  hyperplastic  synovitis,  and  results  finally  in  ankylosis. 
Less  often  the  ankle  is  attacked,  but  any  joint  in  the  body  may  be  affected. 
The  skin  may  exhibit  syphilitic  tubercles  and  gummata  in  various 
situations,  but  not  so  frequently  as  in  acquired  syphilis.  They  tend  to 
break  down  and  leave  ulcers,  often  covered  by  thick  crusts  and  finally 
replaced  by  scars.  A  papular  eruption  of  the  face  may  develop  during 
relapses.  Condylomata  are,  as  stated,  the  cutaneous  manifestations 
particularly  lial)Ie  to  appear  during  relapses,  and  may,  indeed,  be  the 
only  cutaneous  lesion  after  the  1st  year  and  in  early  childhood.  They 
are  the  commonest  of  all  symptoms  at  these  times  but  are  not  frequent 
1  Pfaundler  and  Schlossmann;  Handb.  d.  Kinderh.,  1900,  I,  2,  920,  931. 


576 


THE  DISEASES  OF  CHILDREN 


after  this  period.     In  general,  the  longer  the  time  elapsed  since  infancy, 
the  less  pronounced  as  symptoms  do  cutaneous  eruptions  become. 


Fig.   193. — Hydrarthrosis  in  Later  Hereditary  Syphilis. 
Courtesy  of  Dr.  J.  F.  Schamberg. 

The  incisor  teeth  of  the  second  dentition,  especially  the  two  upper 
central  ones,  show  very  characteristic  changes,  described  by  Hutchinson^ 


Fig.   194. — Hutchinson's  Teeth  in  Later  Hereditary  Syphilis. 
Courtesy  of  Dr.  J.  F.  Schamberg. 

(Fig.  194),     They  are  far  apart  and  small,  with  notching  of  the  cutting 

surface.     In  other  cases  they  are  tapering  and  characteristically  "peg- 

1  Brit.  Med.  Journ.,  1858,  II,  822. 


SYPHILIS  577 

shaped."  Mucous  placques  and  ulcers  appear  on  the  mucous  membrane 
of  the  mouth,  tongue  and  pharynx,  and  alterations  of  the  larynx  may 
develop. 

Enlargement  of  the  lymphatic  glands,  referred  to  as  seen  in  infancy, 
becomes  more  common  after  the  1st  year.  The  nervous  system  is  involved 
in  many  diverse  ways  in  the  later  symptoms  of  hereditary  syphilis,  al- 
though not  as  frequently  as  in  adults.  The  pseudo-paralysis  described 
appears  exceptionally  to  be  of  nervous  origin.  Paralysis  of  the  cranial 
nerves  may  occur  dependent  upon  meningitis,  encephalitic  processes  the 
result  of  endarteritis,  or  gummatous  growths.  Retarded  mental  develop- 
ment perhaps  not  appearing  until  later  childhood,  idiocy,  and  epilepsy 
have  been  described,  and  juvenile  paresis  or  tabes  is  sometimes  observed. 

The  eye,  likewise,  exhibits  late  symptoms.  Chronic  interstitial  kera- 
titis is  one  of  the  most  frequent  of  these.  It  generally  occurs  in  later  child- 
hood, attacks  both  eyes,  and  produces  slight  cloudiness,  or  even  entire 
opacity  of  the  cornea,  which,  however,  usually  disappears  under  treat- 
ment. Choroiditis,  iritis,  and  retinitis  may  occur.  Hearing  may  be 
affected  by  chronic  otitis,  or,  in  older  children,  by  a  disturbance  which  is  of 
nervous  origin,  perhaps  labyrinthine.  The  latter  is  very  characteristic. 
It  may  result  in  deaf-mutism.  Syphilis  of  the  internal  organs  may  also 
be  among  the  later  symptoms,  dependent  upon  interstitial  changes  or  the 
formation  of  gummata.  Decided  enlargement  of  the  liver  and  spleen 
may  occur,  and  combined  with  this  is  alteration  of  the  blood,  great  anemia 
developing  with  diminution  in  the  number  of  red  blood-cells  and  hemo- 
globin and  increase  of  leucoyctes;  and  a  clinical  picture  may  result 
suggesting  Banti's  disease  (Osier). ^  Interstitial  nephritis  may  develop, 
and  the  pancreas  and  testicles  sometimes  exhibit  lesions. 

Reviewing  the  later  symptoms  described  it  will  be  noticed  that  some 
are  characteristic  of  relapses  in  infancy  and  early  childhood,  while  others, 
chiefly  of  true  late  hereditary  syphilis,  appear  oftenest  about  the  period 
of  puberty.  Among  the  former  are  condylomata  of  the  skin  and  mucous 
membranes,  debility,  retardation  of  growth,  deformities  of  the  skull, 
dactylitis,  and  enlargement  of  the  lymphatic  glands.  Among  the  latter 
are  osteoperiostitis,  gummata  in  various  regions  including  the  viscera, 
affections  of  the  teeth,  keratitis,  labyrinthine  deafness,  affections  of  the 
knee-joints,  and  retarded  mental  development  and  other  psychic  dis- 
turbances. Gummata  may,  however,  occur  at  an  earlier  period,  and 
visceral  involvement  may  take  place  in  the  early  relapses  or  as  a  quite 
late  symptom,  as  well  as  being  seen  in  the  new  born  and  the  fetus.  Indeed 
there  is  no  sharply  dividing  line  between  the  ages  at  whi  ch  the  various 
later  symptoms  may  show  themselves..  It  is  rather  the  stage  of  the  dis- 
ease which  is  to  be  considered. 

Prognosis. — The  prognosis  of  hereditary  syphilis  varies  with  the 
severity  of  the  infection,  and  with  the  promptness  and  thoroughness  of 
treatment.  A  large  proportion  of  syphilitic  mothers  abort,  or  are 
delivered  of  still-born  children,  and  those  infants  born  alivo  with  decided 
evidences  of  fetal  syphilis  nearly  always  die  soon.  Taking  all  cases 
together  the  death-rate  is  high.  Coutts^  in  1102  syphilitic  pregnancies 
reported  376  abortions  and  396  early  deaths,  making  a  total  death-rate 
of  70.05  per  cent.,  without  including  the  deaths  occurring  later  in  life. 
In  a  series  of  414  pregnancies  reported  by  Le  Pilour^  154  aborted,  and 

1  Clin.  Jotirn.,  1014,  XLIII,  462. 

2  Lancet,  18'J(i,  1,  971. 

3  Th^e  de  Paris,  1851.     Rof.,  FouriiiL-r,  312. 
37 


o78  THE  DISEASES  OF  CHILDREN 

of  260  infants  born  alive  141  died  in  a  very  short  time.  The  total 
mortality  equalled  71.26  per  cent.  These  two  series  occurred  in  hospital 
practice.  Apart  from  this,  however,  the  death-rate  usually  does  not 
reach  these  figures.  Thus,  in  a  series  of  1127  pregnancies  in  syphilitic 
families,  reported  by  Fournier^  occurring  in  the  civic  population  of  Paris 
in  private  practice  the  mortality  in  the  offspring,  including  abortions, 
equalled  but  42  per  cent.  The  majority  of  infants  apparently  healthy 
at  birth  and  showing  no  symptoms  for  some  weeks,  can  be  saved  by 
energetic  treatment.  In  general,  the  less  recent  the  disease  in  the 
parents,  the  better  the  state  of  nutrition  in  the  infant  when  the  symp- 
toms appear,  the  greater  the  delay  in  the  appearance  of  these  symptoms 
and  the  less  their  intensity,  and  especially  the  earlier  antisyphilitic  treat- 
ment is  commenced  after  birth,  or  preferably  before  it,  the  greater  will 
be  the  probability  of  the  child  living. 

Very  important,  too,  is  the  influence  of  a  supply  of  suitable  nourish- 
ment, especially  breast-milk,  children  fed  in  this  way  having  a  far  better 
chance  of  survival.  It  is  noteworthy,  also,  that  the  later  children  of 
syphilitic  parents  oftener  survive  than  do  the  earlier  ones.  Death  is  due 
not  so  much  to  the  lesions  themselves,  unless  the  viscera  are  decidedly 
involved,  as  to  the  profound  effect  which  the  virus  exerts  upon  the  con- 
stitution, with  the  general  asthenia  which  results  and  the  ease  with  which 
complicating  processes,  such  as  sepsis,  pneumonia,  intestinal  disorders, 
and  the  like,  develop  and  determine  a  fatal  ending.  The  degree  of  the 
marantic  symptoms  constitutes  probably  the  most  important  prognostic 
guide.  There  is  always,  too,  to  be  remembered  the  tendency  to  repeated 
relapses,  these  sometimes  occurring  in  spite  of  thorough  specific  treat- 
ment. They  constantly  diminish  in  intensity,  however,  if  treatment 
is  persisted  with. 

There  is  a  tendency  for  symptoms  of  the  tertiary  type  to  appear  in 
later  childhood,  even  in  cases  which  have  been  apparently  entirely  cured 
earlier,  although  still  more  so  in  those  who  have  never  recieved  early 
treatment.  Most  of  these  cases  yield  to  treatment  unless  severe  visceral 
manifestations  are  present,  especially  of  the  kidneys  and  liver.  The 
nervous  manifestations,  too,  are  often  entirely  resistant. 

The  duration  of  the  disease  is  very  uncertain.  Under  proper  treat- 
ment in  favorable  breast-fed  subjects  the  characteristic  cutaneous  erup- 
tions generally  disappear  in  3  to  4  weeks;  the  rhagades,  glandular  swell- 
ing and  snuffling  lasting  a  longer  time,  the  last  mentioned  being  one 
of  the  most  resisting  symptoms.  The  asthenia  and  anemia,  however, 
may  remain  after  other  symptoms  have  disappeared,  and  the  child  may 
die  of  causes  not  directly  syphilitic.  Only  long  persistence  in  treatment 
can  prevent  the  return  of  symptoms  or  the  development  of  new  ones. 
Untreated  infants  lose  the  cutaneous  eruption  in  a  few  weeks  but  soon 
relapse.  The  later  symptoms  of  the  tertiary  type  yield  only  slowly, 
but  the  prognosis  as  regards  life  is  much  better,  Rabdl-  finding  only  9 
deaths  in  93  cases.  The  chance  of  ultimate  recovery  under  satisfactory 
continued  treatment  is  well  illustrated  in  the  statistics  of  Hochsinger:^ 
Of  263  cases  kept  under  observation  for  from  4  to  12  years  79  had  died, 
112  exhibited  symptoms  of  some  sort,  not  always  syphilitic,  and  72  were 
entirely  free  from  symptoms  of  any  kind. 

The  prognosis  of  acquired  syphilis  in  infancy  is  very  much  better  than 

1  L'heredit6  syphilitique,  1891,  309. 

2  Lues  hereditaria  tarda,  1887.     Ref .,  Gerhardt's  Handb.  d.  Ivinderkr. ;  Syphilis,  389. 
«  Ergebn.  d.  inn.  Med.  u.  Kinderh.,  1910,  V,  125. 


SYPHILIS  579 

of  the  hereditary  disease,  owing  to  the  absence  of  the  severe  constitu- 
tional impression  made  by  the  latter.  Fournier^  saw  only  1  death  in  42 
cases. 

Diagnosis. — The  diagnosis  is  easy  in  typical  cases  with  the  group  of 
characteristic  sjonptoms.  In  the  fetus  and  new  born  it  rests  principally 
upon  the  enlargement  of  the  spleen  and  liver,  coryza,  and  osteochon- 
dritis. In  early  infancy  the  most  representative  symptoms  are  snuffling, 
hoarseness,  cutaneous  eruptions,  fissures  about  the  mouth  and  anus, 
and  the  debilitated  condition  present  from  birth  or  developing  later. 
Relapses  are  characterized  by  return  of  symptoms  or  the  development  of 
condylomata  and  sometimes  of  visceral  involvement.  Among  the  much 
later  diagnostic  symptoms  of  hereditary  syphilis  the  most  important  are 
the  alteration  of  the  teeth; the  development  of  gummata  in  various  regions, 
especially  the  cranium  and  the  tibise;  interstitial  keratitis;  deafness  of 
central  origin ;  depression  of  the  bridge  of  the  nose  from  destructive  lesions : 
ulcerations  of  the  interior  of  the  nose  or  of  the  palate;  enlargement  of 
the  lymphatic  glands;  thickening  and  curvature  of  the  tibise;  decided 
hyperplasia  of  the  liver  and  spleen,  and  general  retarded  development. 

In  mild  cases  of  syphilis  where  no  characteristic  group  of  symptoms 
is  present,  the  diagnosis  apart  from  serum-tests  is  difficult.  The  known 
presence  of  syphilis  in  the  parents,  or  the  occurrence  of  repeated  earlier 
abortions  may  confirm  the  importance  of  a  few  suspicious  s^nrnptoms  in 
the  infant.  So,  too,  response  to  antisyphilitic  treatment  is  important 
diagnostically. 

Cutaneous  sjTnptoms  may  be  very  little  marked  in  the  syphilitic 
cases  and,  when  present,  are  carefully  to  be  distinguished  from  various 
non-specific  affections  of  the  skin.  The  maculo-papular,  cutaneous 
eruptions  of  syphilis  differ  from  those  not  syphilitic  chiefly  in  their  situa- 
tion and  their  color.  In  syphilis  they  are  principally  found  on  the  face 
and  the  lower  extremities,  and  exhibit  always  a  tendency  to  a  coppery 
or  raw-ham  tint.  The  diffuse  syphilitic  infiltration  sometimes  resembles 
eczema  intertrigo,  but  is  distinguished  by  the  absence  of  the  intense 
red  color  of  the  latter  and  the  presence  of  a  coppery  or  yellowish-brown 
tint  and  a  tendency  to  scaling,  combined  with  the  evidence  of  infiltra- 
tion of  the  skin  which  produces  a  decided  hardness  and  stiffness.  Syphil- 
itic pemphigus  is  situated  on  an  indurated  base  and  generally  occupies  the 
soles  and  the  palms,  thus  distinguishing  it  from  other  pemphigoid  erup- 
tions in  the  new  born. 

Coryza  in  the  early  weeks  or  months  of  infancy,  without  fever  and  not 
yielding  to  ordinary  forms  of  treatment,  is  suspicious,  even  though  no 
other  symptoms  are  discoverable.  Infantile  scurvy  may  be  mistaken 
for  the  osteo-chondritis  of  syphilis.  In  the  latter,  however,  the  lesion 
is  nearer  the  epiphysis,  and  the  process  usually  begins  at  an  earlier  age. 

The  value  of  the  complement-fixation  reaction  in  the  diagnosis  of 
syphilis,  as  applied  by  Wasscrmann,  Neisser  and  liruck-  and  as  modified 
by  others,  has  been  supported  b}^  the  testimony  of  numerous  later  inves- 
tigators. It  would  appear  that  although  a  positive  Wassermann  reac- 
tion is  of  very  great  importance  a  negative  result  is  of  decidedly  less 
value.  When  for  any  reason  it  cannot  well  be  applied  to  the  infant,  the 
test  may  be  made  up.in  the  mother.  The  performing  of  the  test  requires, 
however,  mucii  training  and  skill,  and  even  with  this  it  is  probable  that 
it  cannot  l)c  absolutely  relied  upon  in  the  aljsencc  of  clinical  symj)toms. 

1  La  svpliilis  lirrcditairc  t.'irdivc,  ISSd,  (lOO. 

2  Deutscli.  iiicd.  Wocliciisilir.,  VM)y\.  XXXII,  745. 


580  THE  DISEASES  OF  CHILDREN 

It  must  be  looked  upon  as  corroborative  evidence.  (See  review  by  Towle.)^ 
Symmers  and  Darlington-  after  a  long  series  of  observations  concluded 
that  a  negative  reaction  was  present  in  from  31  to  56  per  cent,  of  cases 
with  characteristic  post-mortem  lesions  of  syphilis,  and  a  positive  reac- 
tion in  at  least  30  per  cent,  of  cases  without  syphilitic  lesions  found  at 
autopsy.  It  is  to  be  noted,  too,  that  not  infrequently  the  Wassermann 
reaction  does  not  appear  until  after  the  first  few  weeks  of  life,  even  when 
prominent  symptoms  of  syphilis  are  present;  while,  on  the  other  hand, 
a  temporary,  more  or  less  positive  reaction  may  be  obtained  in  various 
non-syphilitic  affections,  among  them  tuberculosis,  scarlet  fever,  leprosy, 
cachectic  conditions  and  certain  cutaneous  disorders. 

The  value  of  the  Noguchi^  luetin  cutaneous  test  is  still  under  dispute. 
An  analysis  by  Comby*  of  publications  upon  the  subject  indicates  that 
it  has  not  fulfilled  expectations.  As  there  is,  however,  decided  evidence 
in  its  favor  from  other  sources  (Wolfsohn,^  DeBuys  and  Lanford,^  and 
others),  further  study  is  required. 

The  differentiation  of  the  hereditary  from  the  acquired  form  depends 
principally  upon  the  early  occurrence  of  visceral  lesions  and  the  existence 
of  epiphysitis,  pseudoparalysis,  fissures,  coryza,  pemphigus,  diffuse 
infiltration  of  the  skin,  or  other  symptoms  characteristic  of  the  inherited 
disease  but  not  seen  in  acquired  syphilis.  In  acquired  syphilis,  on  the 
other  hand,  there  occur  a  primary  lesion,  visceral  involvement  later  in 
the  attack  and  less  frequently,  and  roseola. 

Treatment.  Prophylaxis. — According  to  the  advice  given  by  Four- 
nier^  a  syphilitic  adult  should  undergo  energetic  treatment  more  or  less 
continuously  for  from  3  to  4  years  after  the  onset  of  the  disease,  and 
for  2  years  there  should  have  been  no  symptom  whatever  discoverable. 
Marriage  may  now  take  place,  although  there  is  even  then  no  absolute 
certainty  that  the  disease  will  not  be  transmitted  to  the  offspring.  If 
a  woman  becomes  pregnant  and  her  husband  is  syphilitic,  she  should 
at  once  undergo  continuous  treatment  throughout  pregnancy,  whether 
or  not  she  herself  exhibits  symptoms.  If  she  has  formerly  shown  evi- 
dences of  syphilis,  but  appears  to  have  recovered,  she  should  still  receive 
treatment.  It  is  probable  that  by  these  means  the  infant  will  escape  the 
disease. 

All  healthy  infants  should  be  guarded  with  care  against  the  acquiring 
of  postnatal  syphilis  especially  from  a  syphilitic  wet-nurse,  and  a  thorough 
examination  of  the  nurse  should  be  insisted  upon,  including  an  examina- 
tion for  the  Wassermann  reaction.  It  is  probable  that  an  apparently 
healthy  infant,  born  of  a  syphilitic  mother  may  be  suckled  by  her  without 
danger  of  infection  (Prof eta's  Law).  At  the  same  time,  in  view  of  the 
difference  of  opinion  still  regarding  this,  the  immunity  of  the  infant 
should  not  be  trusted  absolutely,  and  the  mother  should  receive 
treatment  and  should  avoid  caressing  the  infant  or  other  unnecessary 
contact  with  it.  Promiscuous  kissing  of  the  baby  by  friends  or  strangers 
is  also  to  be  avoided. 

It  has  been  denied  that  hereditary  syphilis  is  contagious,  and  it  seems 

lAmer.  Journ.  Dis.  Child.,  1912,  IV,  180;  1914,  VII,  318. 
-  Journ.  Amer.  Med.  Assoc,  1918,  LXX,  279. 
3  Jour.  Exper.  Med.,  1911,  XIV,  557. 
*  Arch,  de  m6d.  des  enf.,  1915,  XVIII,  602. 
•    5  Journ.  Amer.  Med.  Assoc,  1913,  LX,  1855. 
6  Amer.  Journ.,  Dis.  Child.,  1916,  XII,  387. 
^  Syphilis  et  Mariage,  1880. 


SYPHILIS  581 

certain  that  the  transmission  of  the  disease  by  infants  with  this  form  of 
the  affection  is  uncommon.  Nevertheless  it  is  equally  certain  that  such 
transmission  can  at  times  occur  and  syphilis  be  acquired  by  other  children 
of  the  family  through  kissing  the  affected  infant,  or  through  contact  with 
contaminated  spoons,  cups,  toys  and  the  like.  Werther^  records  10  cases 
in  which  the  nurses  were  infected  by  the  infant. 

Treatment  of  the  Disease. — Immediately  after  birth  in  the  case  of 
infants  whose  parents  are  known  to  be  syphilitic;  or,  in  other  cases,  on 
the  first  evidence  of  the  disease  in  the  infant;  treatment  with  mercury 
should  be  commenced.  The  drug  may  be  administered  in  various  ways. 
A  popular  method  is  that  of  rubbing  into  the  skin  daily  5  to  10  grains 
(0.32  to  0.65)  of  mercurial  ointment,  selecting  different  situations  upon 
different  days,  as  the  axilla,  abdomen,  groins,  thighs,  etc.,  in  order  to 
avoid  the  production  of  cutaneous  irritation.  A  favorite  method  is  to 
place  the  ointment  upon  the  binder,  and  thus  keep  it  in  contact  with  the 
abdomen.  The  skin  should  be  washed  with  soap  and  warm  water 
before  every  inunction,  and  the  ointment  gently  rubbed  in  for  10  or  15 
minutes.  In  order  also  to  avoid  irritation,  if  the  skin  is  the  seat  of  any 
extensive  cutaneous  eruption,  the  ointment  may  be  replaced  by  the  sub- 
limate bath,  using  5  to  15  grains  (0.32  to  0.97)  of  the  bichloride  of  mercury 
to  each  bath  of  5  gallons  (19  liters)  given  daily.  The  water  should  be 
heated  to  from  100°  to  105°F.  (37.8°  to  40.6°C.)  and  the  child  should 
remain  in  it  for  from  5  to  15  minutes. 

Instead  of  these  methods,  or  in  addition  to  them,  mercury  may  be 
given  internally,  either  as  calomel,  Ho  of  a  grain  (0.0065) ;  the  protiodide 
/'^o  to  }y{o  of  a  grain  (0.0033  to  0.0065);  hydrargyrum  cum  creta,  1 
to  2  grains  (0.065  to  0.13)  or  corrosive  subhmate,  ^^loo  to  3^:50  of  a  grain, 
(0.0006  to  0.0013)  3  or  4  times  a  day.  If  the  mercury  produces  diarrhea, 
its  administration  should  be  stopped  for  a  few  days  or  a  very  small  amount 
of  opium  given.  Corrosive  sublimate  is  rather  more  prone  than  the  other 
preparations  to  occasion  digestive  disturbance.  Salivation  rarely  occurs 
in  early  infancy,  and  less  frequently  in  children  than  in  adults. 

Mercurial  treatment  to  be  effective  and  lasting  must  be  persisted 
with  for  1  to  2  years,  if  it  does  not  produce  stomatitis  or  anemia  and  de- 
bility. If  any  such  effects  develop  it  should  be  stopped  for  a  time.  In " 
any  event  it  is  often  better  to  allow  brief  periods  of  intermission  to  occur, 
and  it  is  not  necessary  to  employ  the  treatment  so  energetically  during 
the  whole  of  the  period.  Treatment  should  be  given  at  intervals  during 
the  succeeding  years  of  infancy  and  early  childhood,  and  again  at  puberty, 
in  order  to  insure  a  continued  absence  of  symptoms. 

Arsenic,  especially  in  the  form  of  arsphcnamine  in  some  of  its  forms 
(salvarsan,  arsenobenzol,  etc.),  has  come  into  great  prominence  in  the 
treatment  of  syphilis.  Of  its  power  there  is  no  question ;  l)ut  the  preponder- 
ance of  opinion  appears  to  be  that  for  hereditary  syphilis  it  is  not  as 
valuable  as  is  mercury,  although  its  action  is  often  more  rapid;  and  that 
success  is  obtained  only  when  the  administration  of  mercury  is  combined 
with  it.  Its  employment  is  also  not  without  danger  in  nurslings,  and  a 
number  of  deaths  have  been  reported.  Later  in  childhootl,  and  in  severe 
cases  in  infancy  when  a  rapid  effect  is  urgent,  it  often  fills  a  useful  jjlace. 
It  is  irritating  to  the  tissues,  and  should  l)e  given  intravenously  in  doses 
of  0.02  to  0.05  grams  (0.31  to  0.77  grains)  for  very  young  infants,  and  in 
proportionately  larger  amounts  for  those  older.  There  is,  however,  a 
wide  variation  in  opinion  regartling  tiie  size  of  tiie  dose.  Treatment 
'  Miincli.  nied.  Woch.,  1<)1S,  L.W,  71. 


582  THE  DISEASES  OF  CHILDREN 

with  mercury  should  be  combined  with  the  arsenical  preparation;  giving 
the  latter  every  14  days  or  oftener,  the  opinion  regarding  this  being  at 
variance,  and  the  mercurial  persistently.  From*4  to  6  arsenical  injections 
may  be  needed,  the  time  for  the  cessation  of  the  treatment  being  deter- 
mined, as  a  rule,  by  the  disappearance  of  the  Wassermann  reaction. 
In  this  connection  is  to  be  observed,  however,  that  this  disappearance  is 
often  very  difficult  to  accomplish,  especially  in  late  hereditary  syphilis. 

Iodide  of  potassium  or  of  sodium  is  of  service  only  for  the  distinctly 
later  manifestations  of  syphilis,  such  as  occur  in  later  relapses;  and  at 
any  period  when  the  viscera  or  the  bones  are  involved.  The  earlier 
relapses,  with  condylomata,  require  the  use  of  mercury.  The  employment 
of  the  iodides  depends  upon  the  nature  of  the  symptoms,  irrespective  of 
whether  they  occur  in  infancy  or  after  it.  They  may  be  given  to  infants 
in  doses  of  from  2  to  10  grains  (0.13  to  0.65)  3  times  daily ;  alone  or,  often 
better,  combined  with  the  external  use  of  mercury.  The  treatment  must 
be  persisted  with  for  a  long  time.  The  combination  with  mercury  is 
especially  indicated  in  visceral  syphilis. 

Very  important  at  all  periods  is  treatment  of  a  general  tonic  nature. 
In  early  infancy  the  general  nutrition  must  be  supported  or  increased 
by  suitable  nourishment,  especially  by  the  use  of  human  milk,  and  by 
the  use  of  all  hygienic  measures  calculated  to  increase  the  vigor,  which 
so  often  falls  below  normal  in  syphilitic  infants.  For  the  anemia  and 
debility  which  commonly  develop  among  the  later  symptoms,  iron  and 
cod-liver  oil  are  of  value,  and  may  with  benefit  replace  for  a  time  the 
administration  of  mercury.  For  such  cases,  too,  exposure  to  fresh  air 
and  sunshine  and  the  employment  of  similar  hygienic  measures,  with 
abundant  nourishment,  are  especially  important. 

Local  Treatment. — Many  of  the  lesions  require  local  measures  to 
hasten  theu'  cure.  Condylomata  and  cutaneous  ulcerations  and  fissures 
may  be  dusted  with  calomel,  covered  with  mercurial  ointment,  or  painted 
with  a  solution  of  nitrate  of  silver.  Ulcers  on  the  mucous  membranes 
require  careful  cleansing  followed  by  the  application  of  calomel  or,  occa- 
sionally, nitrate  of  silver.  Gummatous  ulcerations  are  well  treated  with 
iodoform  or  mercurial  applications.  The  coryza  is  often  benefited  by 
■removing  crusts  from  the  nose,  followed  by  the  application  of  a  diluted 
yellow  oxide  of  mercury  ointment  or  by  the  insufflation  of  calomel  well 
diluted  with  sugar  (1  :  20). 


SECTION  III 

GENERAL  AND  NUTRITIONAL  DISEASES 

Here  may  be  classified  a  number  of  disorders,  the  cause  and  nature  of 
which  is  not  clearly  understood,  or  which  seem  to  belong  properlj^  to  no 
other  category.  Of  these,  rheumatism  is  now  very  frequently  placed 
among  the  acute  infectious  disorders;  yet,  inasmuch  as  its  position  here 
is  not  yet  positively  proven,  and  on  account  of  its  relationship  to  certain 
other  affections,  it  has  been  thought  best  to  place  it  provisionally  in  the 
class  now  to  be  considered.  Rachitis,  scorbutus  and  some  forms  of 
malnutrition  and  infantile  atrophy  are  best  classified  as  nutritional 
disorders,  and  may  be  placed  here;  as  may  also  be  diabetes,  the  various 
diatheses,  acidosis  and,  provisionally,  pellagra.  Obesity,  which  could 
properly  be  considered  in  this  connection,  will  be  discussed  under 
Diseases  of  the  Internal  Secretions. 


CHAPTER  I 

RACHITIS 
(Rickets) 


Rickets,  undoubtedly  of  earlier  existence,  was  first  named  Rachitis 
and  clearly  described  by  Glisson.^  It  is  very  widely  spread  in  civilized 
countries,  although  its  prevalence  varies  greatly  with  the  locality.  A 
large  proportion  of  infants  brought  to  the  out-patient  departments  of 
hospitals  in  many  of  the  larger  cities  of  Europe  and  America  exhibit 
the  disease.  Morse^  found  it  in  79.5  per  cent,  of  400  infants  in  Boston, 
and  SchmorP  in  Dresden  evidences  of  the  disease  at  autopsj^  in  89.4 
per  cent,  of  345  children  from  2  months  to  4  years  of  age.  Practically 
all  (96.6  per  cent.)  of  those  from  4  to  18  months  exhibited  the  disease. 
It  was  estimated  to  be  present  in  90  per  cent,  of  the  infants  in  Ham- 
burg (Volland);*  74.9  per  cent,  of  those  of  the  poorer  classes  in  Dun- 
dee (Foggie);^  86  per  cent,  of  infants  in  Riga  (Mey),®  but  in  only 
13.5  per  cent,  in  Christiania  (Quisling).^  It  is  essentially  a  chronic 
disease  of  nutrition,  affecting  the  bones  most  strikingly;  but  general  in  its 
nature  and  involving  as  well  the  ligaments,  muscles,  mucous  membranes, 
nervous  system  and  other  parts  of  the  body. 

Etiology. — This  is  not  known  with  any  certainty,  in  spite  of  the 
great  amount  of  investigation  upon  the  subject.  Many  different  fac- 
tors appear  to  possess  some  etiological  relationship.     Prominent  among 

1  Tractatus  de  rachitide,  etc.,  Lond.,    1650.     Ref.,  Rehn,  Gerhardt's  Handb.  d. 
Ivinderk.,  Ill,  1,  43. 

^  Journ.  Ainer.  Med.  Assoc,  1900,  March  24. 

3  Ergebn.  d.  inn.  Med.  u.  Kindorh.,  1909,  IV,  437.     : 

*  Jahrb.  f.  Kinderli.,  18S4,  XXII,  118. 

6  Scottish  Med.  and  Surfr.  Journ.,  1905,  XVI,  231. 

«  Jahrb.  f.  Kinder,  1S90,  XLII,  273. 

^Arch.  f.  Ivinderh.,  1888,  IX,  293. 

583 


584  THE  DISEASES  OF  CHILDREN 

these  is  diet.  It  is  certain  that  the  disease  is  much  less  frequent  and  less 
severe  in  breast-fed  children  unless  nursing  is  unduly  prolonged,  and  it 
has  been  maintained  that  deficiency  in  the  percentage  of  fat  is  the  chief 
cause  in  artificially  fed  children,  especially  if  combined  with  an  insufficient 
amount  of  proteid  matter  and  an  excess  of  carbohydrates.  There  is  no 
positive  proof  of  the  actual  influence  of  any  one  of  these  dietetic  factors. 
It  is  clear,  at  any  rate,  that  infants  fed  upon  condensed  milk  or  other  pro- 
prietary food  are  especially  prone  to  develop  rachitis,  these  foods  gener- 
ally possessing  just  the  defects  mentioned.  Yet  a  deficiency  in  any  of 
the  food-elements  is  not  the  only  agent,  for  the  disease  may  follow  over- 
feeding as  well  as  under-feeding.  A  very  great  deficiency  in  the  amount 
of  food  given  leads  to  wasting  without  the  development  of  rachitis ;  and 
on  the  other  hand,  it  is  not  infrequent  that  babies  become  rachitic  who 
have  been  fed  entirely  upon  breast-milk  of  the  best  quality.  This  is 
especially  true  of  the  Italians  and  Negroes  in  the  northern  cities  of  the 
United  States.  Of  the  cases  reported  by  Morse^  18  per  cent,  were  breast- 
fed solely.  If  the  food-influences  are  active  agents,  it  is  forced  upon  us 
that  we  do  not  yet  know  in  just  what  the  errors  in  diet  consist. 

Hygienic  conditions  in  general  seem  to  be  important  factors.  Over- 
crowding among  the  poor  in  cities,  with  the  attendant  lack  of  fresh  air  and 
sunlight  and  other  disadvantages,  certainly  predisposes,  and  the  disease 
is  less  common  in  country  districts.  Yet,  on  the  other  hand,  rickets  is 
common,  although  generally  less  severe,  among  the  well-to-do,  where  both 
the  hygienic  surroundings  and  the  diet  have  been  carefully  supervised. 
I  have  repeatedly  seen  it  develop  in  infants  under  the  best  conditions  in 
spite  of  every  precautionary  measure. 

Season  is  of  influence,  the  disorder  being  less  frequent  during  the 
summer  and  sufferers  from  it  seeming  to  improve  at  this  time.  This 
common  clinical  observation  has  been  confirmed  by  the  autopsy-statistics 
of  SchmorP  upon  281  cases  of  rickets.  The  microscopic  study  of 
the  bones  showed  evidences  of  a  beginning  rachitic  process  in  compara- 
tively few  cases  during  the  summer;  while  the  proportion  of  those  with 
evidences  of  healing  was  at  its  maximum  at  this  time.  Geographical 
distribution  and  climate  are  likewise  factors.  The  disease  is  especially 
frequent  in  northern  temperate  climates,  less  common  in  subtropical 
countries,  and  rare  in  the  tropics  and  in  the  far  north.  In  England, 
Austria,  Northern  Italy,  the  Netherlands  and  Germany  it  is  very  common, 
while  it  is  relativelj^  rare  in  China,  Japan,  Greenland,  Turkey,  Denmark, 
Norway,  Greece,  Southern  Italy  and  Southern  Spain  (Palm).^  It  is  less 
common  at  high  altitudes  than  at  lower  elevations  in  the  same  country. 
The  lesser  frequency  in  summer-time  or  in  hot  countries  probably 
depends,  at  least  to  some  extent,  upon  the  greater  open-air  life.  In 
the  tropics,  also,  breast-feeding  is  more  usual. 

Apart  from  locality,  race  seems  to  exert  a  powerful  influence  under 
certain  conditions.  Rickets  is  particularly  prevalent  in  races  from  warm 
regions  transported  to  colder  ones.  Thus  among  the  Italians  and  Negroes 
of  the  northern  cities  of  the  United  States  nearly  every  infant  exhibits 
more  or  less  rickets,  while  in  the  southern  United  States  it  is  far  less 
common  among  the  Negroes,  and  rare  in  these  in  the  tropics,  and  it  is  not 
frequent  in  southern  Italy.  This  racial  prevalence  in  northern  cities 
cannot  be  the  result  of  improper  dietetic  or  hygienic  conditions,  for  these 

1  Bost.  Med.  and  Surg.  Journ.,  1899,  CLX,  163. 

2  Loc.  cit.,  439. 

3  Practitioner,  1890,  XLV,  270. 


RACHITIS  585 

are  in  no  way  inferior  to  those  active  among  the  poor  immigrants  from 
other  countries.  This  brings  up,  naturally,  the  question  of  heredity. 
Although  formerly  denied,  certain  more  recent  investigations  decidedly 
support  the  view  that  the  tendenc}^  to  become  rachitic,  once  having 
developed,  is  readily  perpetuated  and  increased  by  inheritance,  and  this 
seems  to  be  the  most  satisfactory  explanation  of  the  remarkable  race- 
disposition  alluded  to.  Siegert^  especially  has  emphasized  this  fact,  and 
I  have  myself  seen  instances  strongly  corroborative;  and  Zimmern^ 
and  others  have  reported  cases  showing  remarkable  family  tendency. 
There  is,  however,  much  against  the  theory  and  any  decision  must  be 
held  in  abeyance. 

Age  as  a  factor  is  important.  Rickets  is  observed  especially  in  the 
first  2  years  of  life.  It  rarely  shows  itself  clinically  before  the  3d  month 
and  generally  not  until  after  the  6th  month.  Baginsky,^  in  620  cases 
found  symptoms  present  in  43  from  3  to  6  months  of  age;  173  from 
6  to  12  months;  220  from  12  to  18  months;  and  113  from  18  to  24 
months.  It  rarely  begins  after  the  2d  year  of  hfe.  Its  height  is  usually 
about  the  end  of  the  1st  or  the  beginning  of  the  2d  year.  Even  cases 
of  fetal  rickets  have  repeatedly  been  reported,  but  doubt  attaches  to 
most  of  these.  (See  Fetal  Rickets,  p.  598.)  So,  too,  late  rickets  has  been 
described,  the  symptoms  not  appearing  until  later  childhood  or  puberty. 
The  condition  is,  however,  certainly  very  rare  and  does  not  differ  essen- 
tially from  osteomalacia.     (See  Late  Rickets,  p.  598.) 

The  condition  of  the  'parents,  apart  from  the  existence  of  rickets  in 
them,  already  referred  to,  predisposes  to  the  development  of  the  disease 
only  by  the  general  debilitating  effect  upon  the  offspring  or  through  the 
production  of  poor  breast-milk  by  the  mother.  Sex  exerts  no  influence 
of  moment.  Previous  disease  of  the  infant  has  a  definite  influence.  Thus, 
prolonged  catarrhal  states  of  the  digestive  apparatus  may  be  followed  by 
the  disease,  perhaps  through  rendering  the  child  unable  to  profit  by  food 
which,  in  itself,  is  of  good  quality;  perhaps  through  favoring  the  produc- 
tion of  some  toxic  substance  in  the  intestine.  Should  the  digestive 
disturbances  be  severe,  howevel*,  wasting  of  the  child  is  liable  to  occur 
rather  than  rickets,  and,  on  the  whole,  digestive  disorders  are  not  a  very 
prominent  etiological  factor.  Acute  severe  disease  of  any  nature  appears 
sometimes  to  be  the  starting  point  for  rickets,  or  to  make  the  symptoms 
worse  if  already  present. 

Pathogenesis. — The  relationship  of  the  various  etiological  factors 
to  the  pathological  process  resulting  is  not  yet  understood,  and  various 
theories  have  been  advanced.  One  is  that  the  process  depends  upon  an 
insufficient  amount  of  mineral  matter  in  the  food.  For  this  there  appears 
no  good  evidence,  since  the  artificial  food  given  to  infants  is  in  no  respect 
less  well  provided  with  mineral  matter  than  is  human  milk.  The  experi- 
mental feeding  of  young  animals  with  food  deficient  in  lime  has  produced 
a  condition  resembling  osteoporosis,  but  not  the  true  lesions  of  rachitis 
(Schabad).'*  Another  theory  advanced  is  that  the  lime-salts  in  the  food 
may  be  sufficiently  abundant,  but  that  there  is  imperfect  absorption  of 
these  from  the  intestinal  tract.  This  has  been  proven  by  Riidel^  to  be 
incorrect.     The  view  has  likewise  been  expressed  that  the  disease  is 

1  Jahrb.  fur  Kinderhcilk.,  1904,  LVIII,  2:?7. 

2  Nouvelle  iconog.  de  hi  Saltpctrie-ro,  1001,  XIV,  209. 

3  Prakt  Beitrilge  z.  Kindcrlicilk.,  1.SS2.  Kof.  Viorordt,  XolhimRors  Spec.  Path.  u. 
Therap.;  Rachitis,  VII,  2,  1. 

*  Arch.  f.  Kinderh.,  1900,  LII,  47. 

»  Arch.  f.  exp.  Path.  u.  Pharm.,  1894,  XXXIII,  01. 


586  THE  DISEASES  OF  CHILDREN 

produced  by  acid  in  the  blood  which  removes  the  Kme-salts  from  the 
system.  All  theories  involving  an  increased  excretion  of  lime-salts  or  a 
failure  in  the  supply  of  these  to  the  bones  as  the  cause  of  rickets  are 
negatived  by  the  fact  demonstrated  by  Stoltzner^  and  by  Brubacher^ 
that  the  other  tissues  of  the  body  contain  a  normal  amount  of  this 
substance.  It  should  be  stated,  however,  that  Aschenheim  and  Kaum- 
heimer^  do  not  agree  with  this  conclusion.  That  the  calcium  and  phos- 
phorous balance  is  disturbed  in  rickets  has  been  shown  by  Schabad'* 
and  others,  the  excretion  of  both  phosphorus  and  calcium  being  increased 
in  the  acute  stage  and  decreased  during  convalescence.  It  seems  certain 
that  the  bones  are  unable  to  retain  a  normal  amount  of  calcium. 

That  improper  diet  is  instrumental  in  producing  the  disease  in  young, 
wild  animals  in  confinement  seems  indicated  by  various  reported  experi- 
ments. The  results,  however,  are  inconclusive,  since  animals  under  these 
conditions  appear  predisposed  to  rickets  even  when  fed  in  a  proper  manner. 
The  exact  influence  of  diet  is  still  unsolved.  The  theory  of  the  infectious 
nature  of  the  disease  has  been  advocated  by  a  number  of  observers,  but 
has  not  obtained  general  recognition.  Yet  the  great  prevalence  of 
rickets  in  certain  localities,  and  the  comparative  absence  of  it  from 
others  where  dietetic  and  hygienic  conditions  do  not  appear  to  be  any 
more  favorable,  renders  it  possible  that  this  may  be  the  solution. 

Rickets  would  appear,  according  to  some  views,  to  be  essentially  an 
inflammatory  process  in  the  bones,  although  how  this  is  brought  about  is 
unknown,  and  even  the  existence  of  inflammation  at  all  is  denied  by 
other  writers,  who  regard  the  disease  rather  as  an  interference  with  devel- 
opment, the  result  of  the  action  of  some  irritant.  Whether  this  substance 
is  a  toxic  material  from  the  intestinal  canal,  an  abnormal  internal  secre- 
tion, or  some  other  as  yet  unsuspected  agent,  is  not  known.  The  influence 
of  various  of  the  internal  secretions  upon  the  production  has  been  main- 
tained, but  has  not  as  yet  been  proven. 

We  can  only  conclude,  that  in  some  way  in  rickets  there  occurs  a 
failure  of  lime-salts  to  be  deposited  through  some  inability  of  the  bones 
to  absorb  it,  a  cessation  in  the  transformation  of  osteoid  tissue  into 
true  bone;  but  of  the  manner  in  which  this  is  brought  about  we  are 
entirely  in  ignorance.  The  disease  is  a  nutritional  one,  in  which  diverse 
debilitating  factors  appear  able  to  disturb  in  some  way  the  normal  nutri- 
tional balance  of  the  infant,  and  imperfect  metabolic  processes  result. 

Pathological  Anatomy.  Lesions  of  the  Bones. — The  principal 
anatomical  lesions  are  in  the  osseous  sj-stem.  Macroscopically  the  bones 
are  softer  and  more  flexible  than  normal,  the  degree  to  which  they  may 
be  bent  being  remarkable  in  severe  cases.  All  the  bones  of  the  body  are 
affected  but  the  changes  are  especially  marked  in  the  long  bones.  There 
is  enlargement  at  all  the  epiphyseal  junctions,  but  most  decided  at  the 
wrists  and  ankles  and  at  the  costochondral  articulations  (Figs.  195,  196 
and  197),  the  thickening  in  the  latter  position  being  always  much  more 
evident  on  the  pleural  surface.  Moderate  thickening  of  the  shaft  of  the 
long  bones  also  takes  place  and  all  the  distinctions  of  outline  marked  by 
angles,  ridges  and  the  like,  are  less  marked  than  in  normal  bones.  There 
is  also  thickening  of  the  flat  bones  in  certain  regions,  with  the  production, 
especially  upon  the  skull,  of  large  bosses;  while  in  other  portions  of  the 

1  Jahrb.  f.  Ivinderh.,  1899,  L,  268. 

•'  Zeitschr.  f.  Biol.,  1890,  XXVII,  517. 

3  Monatsschr.  f.  Ivinderh.,  Orig.,  1911,  X,  435. 

'  Arch.  f.  Kinderh.,  1910,  LIII,  380;  LIV,  83. 


RACHITIS 


587 


cranium  spots  of  very  thin,  parchment-like  bone  may  be  found  (Cranio- 
tabes).  (See  Vol.  II,  p.  428.)  These  alterations  produce  deformities  of 
many  sorts,  and  fractures  are  common  (Fig.  198) .  The  degree  of  deformity 
varies  greatly,  depending  upon  the  severity  of  the  case.  Arrested  growth 
in  the  length  of  the  bones  may  occur  as  a  result  of  the  changes  in  the 
epiphyses. 


Fig.   195. — Radioguaph  of  the  Wkist  in  Rickets. 
Shows  the  enlarKcrnent  at  the  wrist-joint.     From  a  colored  child,  aged  2  years  aud  9 
months,  in  the  Children's  Hospital  of  Philadelphia. 


LongitU(Hnal  section  shows  the  junction  of  the  shaft  and  the  epiphyses 
much  wider,  thicker  and  softer  than  normal  (Fig.  199)  with  a  broadening 
of  the  bluish,  cartilaginous  layer.  The  centres  of  ossification  are  liyper- 
emic,  spongy  and  enlarged.  It  is  to  this  and  to  the  general  widening  of 
the  cartilaginous  layer,  that  the  enlargement  of  the  epiphysis  is  due. 
The  medulla  of  the  shaft  is  redder  and  more  jelly-like  than  normal  and  the 
medullary  cavity  broadened  and  its  bony  divisions  rarefied.  The  perios- 
teum of  both  the  flat  and  long  bones  is  hyperemic,  and  beneath  it  are 


588 


THE  DISEASES  OF  CHILDREN 


several  layers   of   friable,    spongy,    vascular    tissue,    with   large  inter- 
trabecular  spaces. 

Microscopically    there   are   very   characteristic   changes   seen.     The 
proliferating  layer  of  the  epiphyseal  cartilage,  situated  next  to  the  hyahne 


Fig.  196. — Anatomical  Specimen  of  Rachitic  Chest. 
Shows  the  rachitic  rosary  produced  by  enlargement  at  the  costo-chondral  articulations. 

cartilage,  is  hyperemic  and  the  cartilage  cells  more  numerous  than  nor- 
mal and  irregularly  arranged.  The  columnar  zone  next  to  it  is  still  more 
affected  in  the  same  way,  being  abnormally  wide  and  exhibiting  an 
unusual  length  of  columns  of  cells  and  increase  of  vascularity.     This 


Fig.   197. — Rachitic  Chest  Viewed  fkom  the  Inside. 
Same  case  as  in  Fig.  196. 

is  not  due  to  an  abnormal  production  of  cartilage  but  to  a  failure  of  it 
to  be  transformed  into  bone  in  the  normal  manner  (Schmorl) .  ^  The  layers 
of  cartilage  are  transversed  irregularly  by  canals  containing  much-dilated 
blood-vessels  and  soft,  vascular,  imperfectly  formed  "osteoid"  tissue, 
deficient  in  lime-salts.     The  zones  of  calcification  and,  last,  of  ossification, 

1  Loc.  cit,  424. 


RACHITIS 


589 


are  broader  than  in  healthy  bone  and  have  lost  their  normal,  sharply- 
defined  outlines,  exhibiting  instead  calcified  areas  irregularly  mingled 
with  others  still  cartilaginous,  and  with  scattered,  unusually  large 
medullary  spaces  containing  osteoid  tissue.  This  disappearance  of  the 
sharply-defined  junctions  of  the  zones,  as  seen  in  the  normal  epiphysis, 
with  the  irregular  inroads  of  one  into  the  other,  is  one  of  the  most  striking 
characteristics  of  rickets.  The  spongy  portion  of  the  shaft  exhibits 
increased  vascularity,  with  erosion  of  the  trabeculae,  resulting  in  large, 
medullary  spaces. 


Fig.   198. — Skeleton  of  a  Severe  Case  of  Rickets. 
From  a  negro  child  of  6  years,  in  the  Pennsylvania  Hospital  of  Philadelphia  at  the  time 
of  his  death.     (Donhauscr,  Bull,  of  Ayer  Clinical  Laboratory,  1907,  -Vo.  4,  13.) 


Beneath  the  periosteum  of  both  long  and  flat  bones  an  analogous 
process  is  seen,  with  cell-proliferation,  vascularity,  and  imperfect  calcifi- 
cation, resulting  in  thickening  and  in  the  production  of  osteoid  tissue. 

Chemically  the  rachitic  osseous  tissue  is  very  decidedly  altered  in  the 
amount  of  lime  and  of  phosphorus  contained,  these  being  sometimes 
diminished  to  50  per  cent,  or  even  25  per  cent,  of  the  normal.  The 
percentage  of  organic  matter  and  of  water  is  increased.  These  character- 
istics account  for  the  unusual  degree  of  softness  and  flexibility  of  the 
bones,  which  suffer  in  consequence  from  green-stick  fractures,  with  the 
production  of  a  large  amount  of  callus. 


590 


THE  DISEASES  OF  CHILDREN 


During  recovery  from  the  disease  the  bony  changes  disappear  through 
resorption  and  condensation  of  the  imperfect  bone  taking  place,  and  hme- 
salts  are  again  deposited.  The  development  of  very  hard,  compact, 
dense,  bony  tissue  (eburnation)  results. 

In  brief,  the  osseous  changes  in  rickets  consist  in  unusual  hyperemia; 
excessive  proliferation  of  cartilage;  irregularity  in  the  transformation  of 
cartilage  into  bone,  with  disturbance  of  the  normal  division  into  zones; 
deficient  deposit  of  lime-salts,  with  consequent  over-development  of 
osteoid  tissue  which  fails  to  change  into  true  bone;  thickening  oF'the 
periosteal  layer  through  undue  cellular  production,  and  the  formation  of 
masses  of  osteoid  tissue  here ;  absorption  of  trabeculae  in  the  spongy  bone, 
with  consequent  increase  of  the  medullary  spaces;  and  hyperemia  and 
widening  of  the  central  marrow-cavity. 


Pleural 
side. 


A.  Notch  in  front  of  bead. 


C.  Columnar  zone,  much  enlarged;  it  is  traversed  by 
numerous  vascular  canals,  many  with  osteoid  con- 
tents and  the  cartilage  around  them  partly  ossified. 


f  D.  Large  medullary  spaces  and  small  eroded  trabecule. 


Fig.  199. — I>ongitudinal  Section  of  Rib  of  Rachitic  Child  Aged  15  Months. 
About  3  times  natural  size.     (Barlow  and  Bury,  Keating's  Cyclopcedia  of  the  Diseases 
of  Children,  1889,  //,  241.) 


Lesions  of  the  Soft  Parts  and  Organs. — The  spleen  is  often  enlarged, 
yet  not  necessarily  so.  Catarrhal  conditions  of  the  lungs  are  frequent, 
with  areas  of  atelectasis  and  others  showing  emphysema.  Moderate 
enlargement  and  fatty  infiltration  of  the  liver  may  occur.  The  gastro- 
enteric tract  often  exhibits  catarrhal  inflammation  with  unusual  disten- 
tion of  the  stomach  and  intestines.  The  lymphatic  glands  are  fre- 
quently enlarged.  Thinness  and  weakness  of  the  muscles  are  evident; 
well  seen  in  the  abdominal  walls.  The  ventricles  of  the  brain  are  often 
moderately  dilated. 

Symptoms. — Although  the  skeletal  changes  are  the  most  char- 
acteristic, the  constitutional  symptoms  are  the  first  to  become  manifest. 
These  seldom  are  noticeable  before  the  age  of  3  months,  although  the 
microscopical  changes  in  the  bones  appear  even  in  the  2d  month. 
Among  the  earliest  manifestations  are  head-sweating,  restlessness,  and 
rocking  of  the  head  when  asleep.  These  early  symptoms  develop 
gradually,  and  usually  attract  little  attention.  In  a  short  time  beading 
of  the  ribs  is  noticed  in  nearly  all  cases.  Other  bony  enlargements  now 
develop,  especially  of  the  skull,  ribs,  wrists,  and  ankles,  while  character- 


RACHITIS 


591 


istic  alterations  of  the  shape  of  the  chest  appear  and  the  abdomen  becomes 
pot-beUied.  The  general  health  may  remain  unaffected  at  first,  but 
in  well-marked  cases  the  child  finally  grows  anemic  and  suffers  readily 
from  respiratory  and  gastrointestinal  catarrhal  processes  and  sometimes 
convulsions.  The  teeth  are  late  in  appearing  and  decay  early;  the  fon- 
tanelle  fails  to  close  at  the  proper  time;  growth  of  the  body  is  interfered 
with;  and  when  sitting  and  walking  begin,  at  a  period  much  later  than 
normal,  curvature  of  the  long  bones  and  of  the  spine  is  produced. 


Fig.  200.  Fig.  201. 

Fig.  200. — Rachitis,  Showing  Especially  the  Lateral  Depression  of  the  Thor.vx 
AND  Curvature  of  the  Tibi^. 
From  a  child  in  the  Children's  Hospital  of  Philadelphia. 
Fig.  201.— Rachitis,  Showing  the  Pot-belly  and  the  Distortion  of  the  Extremities 
From  a  child  of  4  years,  in  the  Children's  Medical  Ward  of  the  Hospital  of  the  University 
of  Pennsylvania. 

The  complex  of  symptoms  and  the  general  appearance  of  the  pa- 
tient are  very  characteristic  (Figs.  200  and  201)  and  the  diagnosis  easy. 
A  more  detailed  description  is  required: 

Head.— The  head  appears,  and  often  is,  larger  than  normal  in  its 
horizontal  circumference  and  is  usually  brachycephalic.  The  forehead  is 
prominent,  and  the  occiput  and  vault  flattened.  This  produces  a  pecul- 
iarly box-like  form  (Fig.  202).  The  shape,  which  develops  oftenest  about 
the  end  of  the  1st  year,  depends  largely  upon  the  deposit  of  rachitic 
bone  which  takes  place  especially  upon  the  frontal  and  parietal  eminences, 
along  the  sutures,  and  about  the  fontanellcs.  The  flattening  of  tlic  occipi- 
tal region  is  due  to  pressure  upon  the  pillow;  and  should  the  child  while 
in  bed  lie  very  constantly  on  one  pari(!tooocipital  region,  great  asymmetry 
of  the  head  may  result,  one  oblique  diameter  being  nuich  shorter  than  the 
other,  one  ear  nearer  the  front,  antl  even  one  cheek  more  prominent.  The 
anterior  fontanelle  in  rickets  is  larger  than  normal,  and  its  time  of  closing 


592         .  THE  DISEASES  OF  CHILDREN 

is  delayed,  occurring  sometimes  not  until  after  the  2d  3^ear.  In  severe 
cases  the  posterior  fontanelle  and  the  sutures  remain  open  until  the  end  of 
the  1st  year.  In  the  posterior  portion  of  the  skull  thin,  soft  membranous 
spots  are  often  found  in  the  1st  year  (craniotabes,  Vol.  II,  p.  428).  The 
veins  of  the  scalp  are  distended,  especiallj^  over  the  temporal  regions.  The 
hair  is  quite  commonly  worn  away  from  the  back  of  the  head  by  the  frequent 
rocking  movements.  The  face  seems  small,  the  upper  jaw  being  nar- 
rower than  normal  and  the  lower  somewhat  square.  These  various 
deformities  usually  disappear  as  recovery  takes  place,  but  the  relative  in- 
crease in  size  may  persist  in  severe  cases  to  some  extent  throughout  life. 
The  teeth  usually  appear  late  and  out  of  the  normal  order,  not  infre- 
quently none  having  erupted  during  the  1st  year.  They  often  decay 
early,  and  have  a  tendency  to  exhibit  furrows. 


Fig.  202. — Moderate  Rachitic  Alteration  of  the  Head. 
Shows  the  prominent  frontal  bosses,  in  a  patient,  aged  9  months,  in  the  Children's 
Hospital  of  Philadelphia. 

Thorax. — Beading  of  the  ribs  at  the  costochondral  articulations  is  the 
most  frequent  and  the  earliest  osseous  symptom.  It  is  quite  visible  to  the 
eye  unless  the  infant  is  well  covered  with  fat.  Morse  "^  found  it  in  all  of 
318  cases  of  rickets,  and  the  only  symptom  in  41  per  cent,  of  these.  In 
all  well-marked  cases  there  is  in  addition  a  depression  of  the  cartilages 
anterior  to  the  epiphyseal  enlargements.  A  flattening  or  even  a  concavity 
of  the  sides  of  the  thorax  in  a  vertical  direction  develops,  extending  back- 
ward] to  the  posterior  axillarj^  line  and  downward  about  as  far  as  the  7th 
rib.  As  a  result  of  this  alteration  the  sternum  is  unusually  prominent, 
producing  a  condition  suggesting  "pigeon  breast,"  but  usually  differing 
somewhat  from  the  typical  instances  of  this  seen  in  certain  other  condi- 
tions, in  that  the  whole  sternum  is  pushed  forward  in  a  straight  line, 
without  any  anterior  curvature  of  it.  The  rachitic  thorax  also  exhibits 
bulging  at  the  angle  of  the  ribs  posteriorly,  accompanied  by  a  flattening  of 
the  back.  These  changes  produce  in  well-marked  cases  a  deformity 
known  as  the  "violin-shaped"  chest, 

1  Journ.  Amer.  Med.  Assoc,  1900,  March  24. 


RACHITIS 


593 


In  addition  to  the  vertical  lateral  depression  there  is  a  horizontal  one 
(Harrison's  groove)  caused  by  the  decided  flare  of  the  costal  border.  This 
is  at  about  the  level  of  the  xiphoid  cartilage  and  corresponds  to  the  inser- 
tion of  the  diaphragm.  Occasionally  a  funnel-shaped  depression  of  the 
lower  part  of  the  sternum  occurs.  In  some  cases  the  clavicles  are  thick- 
ened at  the  extremities,  shorter,  and  more  curved  than  normal,  and  may 
show   green-stick  fractures. 

The  thorax  as  a  whole  is  lengthened  in  an  anteroposterior  direction, 
and  is  small  and  narrow,  except  for  the  sudden  widening  of  the  lower 


Fig.  203. — Multiple  Deformities  in  a  Seveue  Case  of  Rickets. 
From  a  child  in  the  Children's  Ward  in  the  University  Hospital,  Philadelphia, 
especially  the  great  contraction  of  the  thorax  with  the  costal  flare. 


Shows 


portion  (Fig.  203).  The  deformities  are  produced  by  the  action  of  the 
muscles  of  respiration,  including  the  diaphragm,  upon  the  very  soft  bones; 
andj  byithe  pressure  of  the  back  against  the  bed,  and  of  the  distended 
stomach  and  intestines  and  the  enlarged  liver  against  the  costal  border. 
Spinal  Column. — This  may  be  normal,  but  a  certain  degree  of  lateral 
curvature  is  connnon  in  infants,  and  may  be  very  persistent.  Still 
more  frequent,  and  always  seen  in  well  marked  cases,  is  a  long  posterior 
curvature    dependent  upon  the  weakness  of  the  ligaments  and  of  the 

3S 


594 


THE  DISEASES  OF  CHILDREN 


muscles  of  the  trunk.  It  usually  disappears  entirely  or  to  a  large 
extent  when  the  child  is  suspended  from  the  arm-pits  (Figs.  204  and  205). 

Pelvis. — In  severe  cases  the  pelvis"  may  become  permanently  de- 
formed, the  anteroposterior  diameter  being  shorter  and  the  outlet 
narrower,  with  thickening  of  the  crests  of  the  ilia. 

Extremities.— Epiphyseal  enlargement  at  the  wrist  (Fig.  201)  is  an 
early  symptom  nearly  always  present,  and  that  of  the  ankle  is  also  very 
frequent.  Similar  enlargement  is  often  discoverable  at  the  lower  end 
of  the|humerus  and  femur,  less  frequently  at  the  upper  end  of  these 
bones  and  of  the  tibia  and  fibula.  Bending  of  the  shafts  of  the  long 
bones  occurs  in  the  lower  extremities,  the  commonest  deformities  being 
knock-knees  and  bow-legs  (Fig.  206).  (See  Vol.  II,  pp.  424,  425.)  The 
tibia  may  be  bent  outward  or  forward  (Fig.  207).     The  femur  is  curved 


Fig.  204. — Rachitic  Spinal  Curvature. 
Very  well  marked  when  child  is  sitting.     Courtesy  of  Dr.  H.  R.  Wharton. 


only  in  the  severe  cases,  and  generally  in  a  forward  and  outward  direction. 
Coxa  vara  is  another  rachitic  deformity.  Sometimes  a  striking  deformity 
results  from  the  child  sitting  cross-legged,  the  femora  being  partlj^  rotated 
outward  and  the  tibia?  and  fibula^  fitting  into  each  other  where  pressure  one 
upon  the  other  has  been  constantly  exercised.  Bending  of  the  humerus  is 
not  common  but  the  bones  of  the  forearm  often  curve  outward.  Green- 
stick  fractures  on  the  concave  side  of  the  bone  are  not  infrequent,  espe- 
cially in  the  forearm  and  the  tibia,  and  add  to  the  deformity.  Bending  is 
produced  largely  by  the  action  of  position  and  of  muscular  pull  upon  the 
soft  bones,  although  partly  by  asymmetrical  growth  of  the  epiphysis.  It 
occurs  in  the  legs  even  before  walking  is  commenced,  but  is  much 
increased  by  it.  The  deformity  of  the  extremities  becomes  a  marked 
symptom  toward  the  end  of  the  1st  year. 


RACHITIS 


595 


Fig.   205.  Vu:.   _'UG. 

Fig.  205. — Rachitic  Spinal  Curvature. 

Sam#  case  as  in  Fig.  204.     Very  decided  diminution  in  the  degree  of  curvature  when 
the  child  is  suspended.     Courtesy  of  Dr.  H.  R.  Wharton. 

Fig.  206. — Severe  Case  of  Rickets. 
Illustrates  the  enlargement  of  the  wrists  and  the  curvature  of  the  legs.     Courtesy  of 
Dr.  H.  R.  Wharton. 


Fkj.   J07. —  Rachitic  Dekuumity,  Showincj  the   CinvATtRE    of   thk    I.imhs    am>    ihb 

Wei.i.-makked  Pot-belly. 
Patient  in  the  Children's  A\'ard  of  the  University  Hospital,  I'liil,i«li'l|)iii!i, 


596  THE  DISEASES  OF  CHILDREN 

Growth  of  the  long  bones  in  length  is  very  commonly  interfered  with, 
especialty  in  the  lower  extremities,  and  in  the  worst  cases  permanent 
dwarfism  may  be  a  final  result.  Occasionally  thickening  of  the  fingers 
occurs.     Flat-foot  is  a  common  rachitic  deformitJ^ 

Ligaments. — Relaxation  of  these  aids  in  producing  deformity.  It  is 
seen  especially  in  the  spine  and  in  the  larger  joints,  aiding  in  the  produc- 
tion of  knock-knee,  over-extension  of  the  knee-joints,  weak  ankles,  and 
scoliosis. 

1^  Muscles. — Lack  of  tone  of  the  muscles  of  the  body  is  a  symptom 
commonly  present.  Thej^  are  poorly  developed,  pale,  and  small.  As  a 
result,  cases  of  well-marked  rickets  are  very  late  in  standing  and  walking, 
this  being  occasionalh'  deferred  even  until  early  childhood  is  well  under 
way.  In  one  instance  a  child  of  4  years  was  una])le  to  walk,  although 
without  any  serious  deformity.     The  lack  of  nmscular  power  is  often 


Fig.  208. — Rachitis,  with  Diastasis  of  the  Recti  .\bdominis. 
Shows  displacement  of  the  intestines  through  the  split  in  the  muscles.     Colored  child 
of  15  months.      (Francine,  Arch,  of  Pediat.,  1904,  Feb.,  116.) 

indeed  so  great  that  the  diagnosis  of  paralysis  may  be  made.  I  have 
seen  the  mistake  occur  repeatedly.  The  condition  of  "pot-belly,"  a 
nearly  constant  symptom  of  rickets,  depends  to  a  large  extent  upon 
weakness  of  the  abdominal  muscles,  although  the  weakness  of  the  gastric 
and  intestinal  walls,  combined  with  the  tendency  to  flatulent  distention, 
aids  in  its  production.  The  abdomen  is  uniformly  distended,  tympan- 
itic, and  not  tender  on  pressure.  Very  commonly  in  marked  cases  there 
results  a  diasta.sis  of  the  external  recti  of  the  abdomen,  well  shown  when 
the  child  attempts  to  raise  itself  from  a  recumbent  position  (Fig.  208). 
Constipation  depends  upon  the  muscular  weakness  of  the  intestinal  and 
abdominal  walls. 

General  Condition. — The  skin  is  usually  pale  and  transparent,  with 
a  tendency  to  enlargement  of  the  veins  in  many  localities,  especially  over 
the  scalp  and  at  the  root  of  the  nose.  Although  often  apparently  well 
nourished,  so  far,  at  least,  as  the  presence  of  adipose  is  concerned,  the 
tissues  of  children  with  rickets  are  nearly  always  flabby.     Severe  cases 


RACHITIS  597 

eventually  lose  considerably  in  weight  and  in  general  health  and  become 
anemic.     The  general  resisting  power  is  slight. 

Digestive  System. — Adenoid  growths  and  tonsillar  hypertrophy  are 
common.  The  sensitiveness  of  the  mucous  membrane  is  shown  by  the 
readiness  with  which  rachitic  subjects  develop  obstinate  catarrhal  dis- 
turbances of  the  stomach  and  intestines  from  slight  causes.  This  aids 
in  producing  the  tj^mpanitic  distention  of  the  stomach  and  intestines 
and  the  characteristic  pot-belly  referred  to.  Constipation  is  common, 
often  alternating  with  diarrhea.  The  liver  is  not  infrequently  enlarged, 
but  this  may  be  only  apparent,  due  to  the  displacement  downward,  the 
result  of  the  distortion  of  the  chest. 

Respiratory  System. — The  mucous  membranes  in  rickets  are  particu- 
larly prone  to  the  development  of  diseased  conditions,  among  them  bron- 
chitis and  bronchopneumonia.  Acceleration  of  respiration,  without  fever 
or  other  discoverable  cause,  and  often  accompanied  by  moving  of  the 
alse  nasi,  is  very  characteristic.  The  breathing  in  well-marked  cases  is 
largely  diaphragmatic,  due  to  the  softening  and  yielding  of  the  frarne- 
work  and  the  weakness  of  the  muscles  of  the  thorax.  The  deformities 
of  the  chest  produce  alterations  in  the  physical  signs  of  auscultation  and 
percussion,  which  may  be  very  misleading  in  the  diagnosis  of  possible 
intra-thoracic  diseases. 

Circulatory  System. — In  mild  cases  the  blood  is  unaffected,  but  in  the 
severer  ones  more  or  less  anemia  usually  develops.  Morse's^  studies  of 
his  own  cases  and  of  the  writings  of  other  investigators  led  to  the  conclu- 
sion that  the  blood  in  rickets  usually  shows  the  red  cells  normal  or  re- 
duced in  number,  and  the  hemoglobin  alwa3'S  reduced  to  a  greater  degree. 
Leucocytosis  is  present  in  about  half  the  cases.  Dilatation  of  the  super- 
ficial veins  is  decided. 

Nervous  System. — Nervous  symptoms  are  very  common,  prominent 
among  them  being  restlessness  at  night,  with  rocking  of  the  head  upon 
the  pillow,  and  constant  tossing  off  of  the  bed-clothes.  The  unusual 
instability  of  the  nervous  system  characteristic  of  rickets  would  appear 
to  predispose  to  convulsive  conditions  of  various  sorts,  as  tetany,  laryngo- 
spasm,  and  particularly  eclampsia.  These  symptoms  are  those,  however, 
of  spasmophilia,  which  seems  in  many  instances  to  be  associated  in  some 
way  with  rickets.  See  Spasmophilia,  Vol.  II,  p.  249.)  In  a  study  of  1 766 
rachitic  children,  Oliari^  found  evidences  of  spasmophilia  in  542.  Pain  in 
the  bones,  especially  evident  when  the  infant  is  lifted  by  grasping  the  chest, 
is  sometimes  .seen.  Although  perhaps  due  in  some  cases  to  the  rachitic 
lesions,  it  is  probably  oftener  dependent  upon  a  complicating  scorbutus. 
In  the  category  of  nervous  affections  may  be  placed  the  profuse  sweating 
of  the  head,  which  occurs  during  sleep  irrespective  of  the  weather,  and 
which  is  sometimes  sufficient  to  moisten  the  pillow.  Fever  may  be 
present,  but  does  not  appear  to  be  a  symptom  of  the  disease.  In  severe 
ca.ses  there  may  be  decided  mental  backwardness  associatetl  with  the 
general  weakness. 

Urine. — Xo  special  alterations  are  discoverable. 

Glandular  System. — The  external  lymphatic  glands  are  frecjuently 
found  enlarged.  Moderate  enlargement  of  the  spleen  is  common  and 
great  increase  in  size  occasional,  but  it  is  still  undetermined  whether  this 
hypertrophy  is  a  symptom  of  rickets  or  only  a  complication.  It  mu.st  be 
remembered,  too,  that  the  wide  costal  fiare  .so  often  present,  and  the 

>  Journ.  .\nier.  Med.  Assoc.  1<KM),  March  24. 
2  La  Pediatria,  1910,  XVIII,  581. 


598  THE  DISEASES  OF  CHILDREN 

diminished  capacitj'  of  the  thorax,  renders  the  spleen  much  more  i-eadily 
feh. 

Fetal  Rickets. — Whether  or  not  such  a  condition  as  fetal  or  con- 
genital rickets  exists  has  been  much  disputed.  It  is  claimed  as  very 
common  by  some,  but  denied  absolutely  by  other  investigators.  Cer- 
tainly it  is  rare  in  the  United  States;  and  it  is,  moreover,  probable  that 
the  majoritj^  if  not  all  of  the  reported  cases  are  instances  of  osteogenesis 
imperfecta  or  of  chondrodystrophy  fetalis  (see  Vol.  II,  pp.  433  and  428), 
which  tiiffer  pathologically  from  the  rachitic  process.  An  elaborate  review 
of  the  subject  by  \Vielan(P  leads  him  to  the  conclusion  that  not  a  single 
case  be3'ond  criticism  has  been  reported. 


Fig.  209. — Late  Rickets. 
Patient  28  years  of  age,  in  whom  the  rachitic  changes  began  at  the  a^e  of  8  years. 
Photograph  talcen  at  the  age  of  21  years,     (von  Bokay,  Arch,  de  m^d.  des  enfants,  1910, 
XIII,  444.) 

Acute  Rickets. — Although  cases  of  this  condition  have  been  described 
in  which  the  symptoms  develop  with  great  rapidity,  it  is  doubtful 
whether  this  condition  is  not  something  entirely  different  from  rickets — 
in  many  cases  certainly  infantile  scurvy.  Other  cases  are,  perhaps,  only 
instances  of  rapid  development  of  rickets  in  a  severe  form,  but  this  cannot 
properly  ha  called  acute. 

Late  Rickets.^ — The  pathological  processes  of  osteomalacia  are  so 
similar  in  some  respects  to  those  of  rickets,  although  the  causes  are  differ- 
ent, that  it  is  probable  that  the  instances  of  so-called  late  rickets,  devel- 
oping in  later  childhood  or  at  puberty,  are  for  the  most  part  properly 
to  be  classified  as  early  osteomalacia.  SchmorP  and  others,  however, 
from  a  careful  study  of  the  subject  maintain  that  genuine  rickets  may 
develop  in  later  childhood.     The  condition  is  certainly  rare.     Its  devel- 

'  Jahrb.  f.  Kinderheilk.,   190S,  LXVII,  675;  Ergobn.  der  inn.  Med.  u.  Kinderh., 
1910,  VI,  64. 

2  Arch.  f.  klin.  Med.,  1905,  LXXXV,  170. 


RACHITIS  599 

opment  is  usually  slow,  the  course  prolonged,  and  the  final  deformities 
very  decided  (Fig.  209). 

Complications  and  Sequels. — The  great  tendency  to  the  develop- 
ment of  respiratory  affections,  especially  bronchitis  and  bronchopneu- 
monia, has  already  been  alluded  to.  Atelectasis  not  infrequently  occurs 
in  infants  with  severe  rachitic  deformities  of  the  chest.  The  gravity  of 
all  respiratory  diseases  in  rachitic  subjects  is  greatly  increased  by  the 
yielding  character  of  the  thoracic  walls  and  the  insufficient  expansion  of 
the  lungs.  The  disposition  to  diarrhea  or  constipation  has  also  been 
mentioned.  General  convulsions  are  common,  as  are  laryngospasm  and 
tetany.  This  tendency  to  the  development  of  spasmophihc  symptoms, 
particularly  convulsions,  is  especially  marked  in  rickets.  Umbilical 
hernia  is  of  frequent  occurrence,  due  to  the  distention  and  thinning 
of  the  abdominal  walls.  Infantile  scurvy  usually  manifests  itself  in 
subjects  already  rachitic,  although  to  this  there  are  frequent  excep- 
tions. Bony  deformities  of  various  sorts  remain  as  sequels,  sometimes 
permanent. 

Course  and  Prognosis. — Rickets  is  a  chronic  but  self-limited  disease. 
The  active  symptoms  usually  continue  not  longer  than  the  beginning  of 
the  1st  and  seldom  more  than  the  end  of  the  2d  year,  their  retro- 
gression being  evidenced  by  the  gradual  spontaneous  cessation  of  head- 
sweating;  the  improvement  of  the  general  restlessness,  irritability,  and 
other  nervous  symptoms;  disappearance  of  anemia;  closure  of  the  fon- 
tanelles;  and  cessation  of  the  disordered  intestinal  and  respiratory  states 
and  of  the  softness  of  the  bones.  Recovery  from  the  bony  deformities 
is  very  slow.  In  most  cases  the  enlargement  of  the  epiphyses  will  finally 
almost  entirely  disappear,  as  will  the  deformity  of  the  skull.  Sometimes, 
however,  the  head  remains  always  larger  than  normal.  Even  moderate 
bowing  of  the  legs  and  other  deformities  disappear  spontaneously  in  a 
remarkable  manner.  Recovery  is  usually  complete  by  the  end  of  the 
3d  or  4th  year.  In  well-marked  cases  of  the  disease,  however,  permanent 
deformities  are  hkely  to  be  present  throughout  life,  in  the  form  of  bow- 
legs, knock-knees,  curvature  of  the  bones  of  the  thigh,  leg,  or  forearm, 
deformities  of  the  chest,  scoliosis,  flat-foot,  rachitic  pelvis,  rachitic  coxa 
vara,  and  dwarfing  from  arrested  growth  of  the  bones  in  length. 

The  disease  in  itself  is  not  dangerous  to  life,  but  through  its  numerous 
comphcations  is  the  cause  of  many  deaths.  The  contraction  of  the  chest 
and  the  lack  of  resiliency  in  its  walls  are  very  serious  factors  should  pneu- 
monia or  pertussis  be  contracted,  and  severe  cases  of  rickets  may  die  from 
ordinary  bronchitis  through  the  development  of  atelectasis.  The  debility 
and  general  loss  of  resisting  power  predispose  to  a  fatal  ending  in  cases  of 
intestinal  disease.  Convulsions  attending  rickets  are  the  cause  of  death 
in  numbers  of  instances. 

Diagnosis. — Well-developed  rickets  is  not  readily  confounded  with 
any  other  disease.  Early  in  its  course  it  is  not  so  easily  recognized.  The 
principal  early  diagnostic  symptoms  are  the  head-sweating,  and  the  rest- 
lessness at  night.  Later  are  evident  the  enlarged  fontanellcs,  character- 
istic shape  of  the  head,  distended  abdomen,  alteration  in  the  shape  of 
the  chest,  rachitic  rosary,  and  the  various  otlier  deforniities  described. 

Certain  other  conditions  occasion  difficulty  in  (Uagnosis.  Hydro- 
cephalus has  a  superficial  resemblance  to  the  raciiitic  head  in  some  in- 
stances. In  both  the  fontanelles  are  large  and  the  sutures  open,  but  in 
hydrocephalus  the  head  is  of  a  more  glol)ular  shape  and  the  sides  protrude 
somewhat  beyond  the  ears,  while  in  rickets  the  shape  is  more  rectangular, 


600  THE  DISEASES  OF  CHILDREN 

with  areas  of  decided  thickening  of  the  bones,  especially  over  the  parietal 
and  frontal  eminences  and  about  the  fontanelles.  Craniotabes  is  not 
positive  diagnostic  evidence  of  rickets,  as  it  may  occur  in  syphilis  also. 

Delayed  dentition,  although  a  diagnostic  symptom  of  rickets,  is  not 
necessarily  so.  If  rickets  is  somewhat  late  in  developing,  the  first  teeth 
may  erupt  promptly;  and,  on  the  other  hand,  it  is  not  infrequent  for  en- 
tirely healthy  infants  to  have  no  teeth  until  the  age  of  10  or  11  months, 
or  even  a  year.  Infantile  scurvy  has  often  been  confounded  with  rickets 
because  the  two  are  so  frequently  combined;  and  the  names  ''scurvy- 
rickets"  and  "hemorrhagic  rickets"  have  been  applied  to  infantile 
scurvy.  Either  disease  can  occur  without  the  other,  and  the  two  have, 
in  reality,  no  symptoms  in  common.  The  tenderness  of  the  bones  which 
sometimes  seems  to  be  a  symptom  of  rickets  is,  in  most  cases,  as  already 
pointed  out,  probably  due  to  a  certain  scorbutic  element.  Infantile 
osteomalacia  has  been  described,  but  is  to  be  considered  identical  with 
rickets  in  most  instances,  although  probably  some  of  the  cases  reported 
belong  to  the  category  of  osteogenesis  imperfecta. 

Osteogenesis  imperfecta  has  often  been  called  "fetal  rickets."  In  it  there 
is  usually  associated  a  remarkable  thinness  of  the  flat  bones,  especially 
of  the  skull,  with  more  or  less  deformity  of  the  long  bones.  It  has  little 
in  common  with  rickets.  Osteopsathyrosis,  or  fragilitas  ossium,  has  like- 
wise often  been  confounded  with  rickets.  It  is  true  that  in  severe  rickets 
there  is  a  decided  tendency  to  the  occurrence  of  fractures,  yet  these  are 
usually  of  the  green-stick  variety,  due  to  softness  of  the  bone.  In  true 
fragilitas  ossium  there  is  nothing  of  the  soft  character  present,  and 
neither  chemically  nor  microscopically  is  there  anything  found  resembling^ 
rickets.  The  two  conditions  are  absolutely  distinct,  as  I  have  pointed' 
out  elsewhere,^  and  osteopsathyrosis  is  more  closely  associated  with  some 
forms  of  osteogenesis  imperfecta. 

Infantile  myxedema  in  its  early  stages  bears  certain  resemblances  to 
rickets.  In  both  there  is  delay  in  dentition  and  in  the  closing  of  the  fon- 
tanelles, and  slowness  in  learning  to  walk.  In  cretinism,  however,  there 
is  an  unusual  slowness  of  growth  in  length,  and  the  peculiar  physiognomy 
of  the  disease,  with  mental  impairment  and  the  general  physical  charac- 
teristics, soon  make  the  diagnosis  easy.  Paralytic  conditions  of  various 
sorts,  with  wasting  of  the  muscles,  sometimes  lead  to  the  suspicion  of 
rickets.  In  all  the  learning  to  walk  may  be  long  delayed,  but  in  none  are 
the  other  symptoms  of  rickets  present ;  while  careful  study  may  show  the 
characteristic  electrical  reactions  and  other  evidences  of  poliomyelitis,  or 
the  spastic  condition  of  a  cerebral  paralysis. 

Syphilis  has  little  in  common  with  rickets.  The  syphilitic  pseudo- 
paralysis occurs  usually  in  the  early  months  of  life,  antedating  the  weak- 
ness of  rickets,  and  the  sabre-tibia  of  later  syphilitic  manifestations  is 
dependent  solely  upon  a  thickening  of  the  anterior  border  of  the  bone 
and  is  unaccompanied  by  other  conditions  suggesting  rachitic  deformities. 
The  spinal  curvature  of  Pott's  Disease  is  short  and  angular  in  shape,  in 
contra-distinction  to  the  long  anteroposterior  curve  of  rickets,  and  when 
well-marked  does  not  disappear  when  the  child  is  lifted  by  the  arms. 

Treatment.  Prophylaxis, — In  the  absence  of  exacb  knowledge 
regarding  the  cause,  prevention  is  difficult.  Certainly  the  most  favorable 
hygienic  conditions  possible  should  be  obtained,  including  abundance  of 
fresh  air  and  sunlight.     The  use  of  proprietary  amylaceous  foods  and 

1  Amer.  Journ.  Med.  8ci.,  1897,  April. 


RACHITIS  601 

of  condensed  milks  should  be  avoided.  Breast-feeding  is  to  be  employed 
whenever  possible.  That  cod  liver-oil  is  of  benefit  after  the  disease  has 
developed  indicates  that  it  might  be  of  service  as  a  prophylactic  measure ; 
and  Hess  and  Unger^  tried  it  with  satisfactory  results  in  a  Negro  com- 
munity, finding  that  the  disease  failed  to  develop  in  80  per  cent,  of  the 
infants  who  received  the  treatment. 

Treatment  of  the  Attack. — This  should  be  commenced  as  early  as 
possible.  Defects  in  diet  should  be  sought  for  and  removed,  as  much 
care  being  taken  to  avoid  overfeeding  as  underfeeding.  Dietetic  changes 
are  necessarily,  to  an  extent,  experimental  in  this  disease;  but  some  altera- 
tion should  be  tried,  even  although  the  infant  seems  to  be  thriving  in 
other  respects.  If  the  feeding  is  manifestly  faulty,  it  should,  of  course, 
be  corrected  in  a  way  to  accord  with  the  needs  of  the  patient.  (See 
Feeding,  p.  108.)  The  use  of  proprietary  infants'  foods  should  be  stopped. 
If  amylaceous  foods  have  constituted  a  large  proportion  of  the  dietary, 
these  should  be  abandoned  largely  for  a  time.  Possibly  an  increase  of 
the  fat  in  the  food  may  be  of  service,  if  well  tolerated  by  the  digestion. 
Beef-juice,  orange-juice,  cooked  fruit,  and  broths  may  be  added  to  the 
diet.  Sometimes  scraped  or  minced  underdone  meat  is  of  advantage. 
Fresh  vegetables  must  be  tried  as  soon  as  the  age  permits.  If  no  cerael 
food  has  yet  been  given,  its  administration  may  be  begun.  In  fact,  a 
varied  diet  is  an  excellent  means  for  the  cure  of  rickets;  and  this  should 
be  commenced  earlier  than  is  commonly  done  with  normal  children;  con- 
tinuing milk  at  least  in  large  enough  amount  to  supply  sufficient  calcium 
to  the  organism.  Caution  must  be  used  in  maldng  any  change,  not 
allowing  it  to  be  too  sudden  or  too  radical,  lest  other  evils  than  rickets 
follow. 

All  other  diseased  conditions,  especially  digestive  disturbances,  must 
be  remedied  as  far  as  possible.  Hygienic  treatment  is  important,  partic- 
ularly life  in  the  open  air,  massage,  cool  baths  when  well  borne,  and  change 
of  residence  to  the  seashore  or  country.  Medicinal  treatment  of  various 
sorts  has  been  employed.  General  experience  has  shown  cod-liver  oil 
to  be  of  unquestionable  benefit.-  It  is  usually  well  borne  except  in  the 
hottest  weather,  and  even  then  may  be  given  tentatively.  Phosphorus 
in  doses  of  >^oo  or  1  ^00  grain  (0.0002  or  0.0003)  3  times  a  day,  has  been 
especially  recommended  by  Kassowitz,'-  and  used  very  extensively  by 
others,  but  its  value  is  very  doubtful  in  the  opinion  of  many.  The  expe- 
rience of  Schabad^  indicates  that  although  phosphorus  exerts  no  in- 
fluence upon  the  calcium-metabolism  in  normal  infants,  yet  when  com- 
bined with  cod-liver  oil  it  favors  the  retention  of  calcium  in  cases  of 
rickets.  This  supports  the  clinical  experience  of  the  value  of  the  com- 
bination of  phosphorus  with  cod-liver  oil  as  reported  in  man}'  quarters. 
Lime  in  various  forms  was  formerly  much  given,  on  the  ground  that  a 
deficiency  of  lime  in  the  food  produced  the  disease.  It  is  now  well  rec- 
ognized by  most  authorities  that  this  theory  is  incorrect,  and  that  the 
administration  of  lime  can  have  no  direct  influence  upon  the  rachitic 
process.  There  is  sufficient  lime  in  the  usual  food  of  infancy.  It  is 
only  during  convalescence,  when  special  demands  may  exist  for  an  un- 
usually large  amount  to  replace  the  deficiency  whi(;h  has  developed, 
that  the  administration  of  lime  may  be  of  possible  value.  It  may 
be  given  in  the  form  of   the  citrate  or  lactate.     Iron,  and  sometimes 

1  Journ.  Amer.  Med.  Assoc,  1917,  LXIX,  1583. 

2  Wien.  med.  Blatter,  1883,  VI,  1492. 

'  Zcit.  f.  kliii.  Med.,  1909,  LXVIII,  94;  1910,  LXIX,  435. 


602  THE  DISEASES  OF  CHILDREN 

arsenic,  are  of  advantage  when  anemia  is  marked,  and  general  tonic 
treatment  should  be  given  when  indicated.  X'arious  organs  and  tissues 
have  been  used  therapeutically  for  rickets,  among  them  thymus  gland 
(^lettenheimer),^  thyroid  gland  (Heubner,-  and  others),  suprarenal  body 
(Stoltzner)^  and  bone-marrow  (Amistani).^  The  value  of  none  of  these 
has  been  established. 

The  development  of  deformities  must  be  carefully  guarded  against. 
Rachitic  children  should  be  discouraged  from  walking  until  the  bones  have 
become  firm.  The  wearing  of  too  thick  a  diaper  predisposes  to  the  devel- 
opment of  bow-legs.  Carrj'ing  the  infant  always  on  the  one  arm  is  verj^ 
likely  to  produce  scoliosis.  Sitting  cross-legged  may  occasion  rotation  of 
the  femora,  indentation  of  the  tibiae,  and  curvature  of  the  forearms  from 
pressure  of  the  hands  against  the  bed  or  floor.  Irregular  distortion  of  the 
head  is  to  be  avoided  by  altering  the  position  in  which  the  child  lies.  The 
treatment  of  deformities  already  acquired  is  considered  fully  in  text- 
books upon  orthopedic  surgery.  Here  only  may  be  mentioned  the 
very  great  value  of  massage  in  strengthening  the  feeble  muscles;  the 
importance  of  favoring  free  movement  of  the  limbs  by  the  patient  by 
creeping  and  b.y  any  other  form  of  exercise,  properly  regulated,  which 
does  not  directly  increase  deformity;  and  the  correction  of  deformities 
by  postural  treatment  and  the  like,  such  as  lying  upon  one  side  with  a 
pillow  under  the  kyphotic  spine;  upon  the  abdomen;  the  gentle  bending 
of  curved  extremities  by  the  nurse;  etc.,  etc.,  according  to  the  nature 
of  the  deformity  present.  Such  measures,  combined  with  general 
treatment,  are  often  completely  efficacious  without  operative  or  special 
orthopedic  procedures.  By  the  age  of  3  years,  however,  and  often 
decidedly  before  this,  the  ossification  of  the  bones  has  become  too  com- 
plete to  permit  of  benefit  being  obtained  in  this  way. 


CHAPTER  II 

SCORBUTUS 
(Infantile  Scurvy) 


This  disease  as  seen  in  early  life  does  not  differ  materially  from  that 
in  adults,  long  known  as  occurring  among  sailors  and  others  deprived 
of  suitable  food.  The  adjective  "Infantile"  is  not  strictly  correct,  since 
the  disorder  is  occasionally  observed  in  children  after  this  period.  In 
infancy  it  was  first  described  by  Moller,''  but  considered  by  him  to  be 
''acute  rickets."  Barlow,"  in  1883,  made  a  careful  study  of  it  and  rec- 
ognized its  true  nature,  and  the  disease  has  often  been  called  after  his 
name.  Numerous  contributions  to  its  literature  have  since  been  made, 
one  of  the  most  extensive  being  the  Collective  Investigation  of  the 
American  Pediatric  Society  in  1898,^  in  which  I  was  actively  interested.^ 
An  able  review  of  the  subject  has  been  published] by  Concetti,^  based 

1  Jahrb.  f.  Kinderh.,  1898,  XLVI,  55. 

2  Bed.  klin.  Woch.,  1896,  XXXIII,  700. 

3  Path.  u.  'i^herap.  d.  Rachitis,  1904. 
^  La  Pcdiatria,  1903,  XI,  560. 

5  Konigsberger  med.  Jahrb.,  1856-7,  I,  377;  1862,  III,  135. 

6  Med.-Chir.  Transac,  LXVl,  1883,  159. 
'  Transac.  Arner.  Pcd.  Soc.,  1S98,  X,  5. 

*  Chairman  of  the  Committee. 

9  Archiv.  f.  Kinderheilk.,  1909,  I,  174. 


SCORBUTUS  603 

upon  these  cases  with  others  collected  from  medical  literature,  equalling 
682  in  all.  A  study  of  93  personal  cases  is  given  by  ]Morse/  and  series 
have  been  published  by  others.  My  own  experience  is  based  upon  some- 
where in  the  neighborhood  of  100  cases.  The  statistics  which  follow  are 
taken  largelj-  from  the  report  of  the  American  Pediatric  Society,  in  which 
379  cases  were  analyzed. 

Etiology. — Age  is  a  predisposing  cause  of  importance,  the  majority 
of  cases  occurring  in  the  latter  half  of  the  1st  year,  and  nearly  all  the 
remainder  before  the  end  of  the  2d  year.  In  Concetti's  series  359 
were  between  the  ages  of  6  and  12  months.  The  youngest  case  in  the 
Society's  report  was  3  weeks  old.  The  disease  was  observed  by  Owen- 
in  a  boy  of  12  years.  Geographical  distribution  seems  to  have  some 
influence.  Infantile  scurvy,  although  nowhere  frequent  as  compared 
with  other  nutritional  disorders,  appears  much  more  common  in  some 
countries,  such  as  England,  Germany  and  the.  United  States,  than  in 
others,  as  France,  Italy  and  Switzerland.  This  may  be  either  because 
feeding  is  more  faulty  in  the  regions  first  mentioned,  or  very  probably 
to  a  large  degree  because  the  attention  of  physicians  has  not  been  directed 
to  it  so  closely  in  the  others,  and  the  disease  has  often  escaped  recognition. 
The  previous  condition  of  health  seems  to  have  no  definite  influence. 
About  1^  of  the  cases  of  the  American  Pediatric  Society's  series  had 
previously  suffered  from  some  digestive  disturbance,  while  ^i  had  been 
in  entirely  good  health.  The  majority  of  cases  in  my  own  experience, 
as  Avell  as  that  of  others,  have  occurred  in  private  practice,  indicating 
that  matters  connected  with  bad  hygiene  and  social  conditions  have  no 
predisposing  influence,  but  rather  the  reverse.  The  active  factor  is  the 
employment  of  an  unsuitable  diet  through  a  period  of  weeks  or  months. 
Just  what  defect  of  diet,  however,  is  the  agent  is  uncertain.  In  356 
cases  in  the  series  of  the  American  Pediatric  Society,  the  diet  was  as 
follows: 

Table  78. — Influence  of  Food  on  the  Incidence  of  Scurvy 

Breast-milk alone  10  cases,  in  combination  2 — total    12 

Raw  cows' milk alone    4  cases,  in  combination  1 — total      5 

Sterilized  milk alone  68  cases,  in  combination  S9 — total  107 

Pasteurized  milk alone  16  cases,  in  combination  4 — total    20 

Condensed  milk alone  32  cases,  in  combination  6 — total    38 

Other  proprietary  foods total  214 

When  mixtures  of  cows'  milk  were  used  nothing  definite  could  be 
learned  in  the  majority  of  cases  regarding  the  composition  of  these,  which, 
doul:)tless,  was  frequently  faulty.  Some  of  the  proprietary  foods  were 
given  with  milk,  some  without.  The  remarkable  influence  of  change 
of  diet  was  shown  in  many  of  the  cases  collected  by  the  Committee,  and 
the  report  justifies  certain  conchisions,  viz.: — That  the  exciting  cause  of 
infantile  scurvy  is  the  long-continued  employment  of  an  unsuitable  diet, 
l)Ut  that  the  fault  differs  with  the  indivi(hial  case,  no  one  diet  alone  being 
icsponsible.  lather  the  needs  of  the  infant  appear  to  demand  something 
wanting  in  the  food,  or  some  harmful  element  is  present.  Looking  at  the 
cases  as  a  whole  it  seems  beyond  question  that  proprietary  infant  foods, 
including  condensed  milk,  are  especially  liable  to  produce  the  di-sease, 
and  tliat  this  is  also  true  of  the  prolonged  heating  of  milk  in  a  considerable 
number  of  instances.  It  seems  entirely  unlikely  that  the  cause  is  a  posi- 
tive one.      Il   is  much  more  probable  that  the  absence  of  some  essential 

'  liosl.  Mc.l.  and  Surfr.  Jouni..  l'H4,  CLXX,  .')04. 
-  Britisli  .Med.  .Invirn.,  lSi»«l,  II,  171<>. 


604  THE  DISEASES  OF  CHILDREN 

substance  of  the  nature  of  a  vitamine,  as  described  by  Funk,^  is  the 
etiological  factor.  Possibly  in  some  instances  this  is  destroyed  by  the 
action  of  heat  in  the  home-preparation  of  milk,  or  as  employed  in  the 
manufacture  of  the  proprietary  foods.  In  those  instances  of  scurvy  in 
which  no  heating  has  been  employed,  there  is  clearly  the  absence  from 
the  beginning  of  the  necessary  element. 

Yet  in  addition,  there  must  exist  an  individual  predisposing  cause, 
the  nature  of  which  is  unknown;  otherwise  scurvy  would  be  far  more 
common  than  it  is,  in  view  of  the  vast  number  of  errors  of  diet  existing, 
and  the  frequencj^  of  sterilization  of  milk-mixtures.  I  have  seen  scurvy 
occur  in  several  members  of  the  same  family  during  their  infancy,  and 
have  even  observed  it  in  twins,  as  though  there  might  be  a  family  tend- 
ency sometimes  existent. 

In  this  connection  the  production  of  scorbutus  experimentally  be- 
comes of  interest.  This  has  been  successfully  accomplished  by  a  number 
of  investigators,  among  them  Hoist  and  Frohlich^  (guinea-pigs;  dogs; 
pigs);  Hart^  (monkeys);  Ingier*  (pigs  and  guinea-pigs);  Fiirst^  (guinea- 
pigs)  ;  Talbot,  Dodd  and  Peterson^  (guinea-pigs  and  monkeys),  all  showing 
that  the  disease  could  be  produced  by  the  absence  from  the  food  of  some 
ingredient,  perhaps  a  vitamine,  which  may  be  different  in  different  cases. 
A  one-sided  diet,  especially  if  consisting  solely  of  cereals,  and  in  some 
instances  condensed  milk  (Dodd  for  monkeys),  was  employed.  The  dis- 
ease was  cured  by  a  change  in  the  diet  to  one  of  a  more  mixed  character. 

Pathological  Anatomy. — The  principal  lesions  are  those  of  the 
bones,  combined  with  a  tendency  to  hemorrhage  in  various  other  regions. 
There  occurs  a  replacement  of  the  bone-marrow  by  an  embryonic  con- 
nective tissue  with  few  vessels  and  cellular  elements.  There  is  an  arrest 
also  in  the  formation  of  bone  from  the  osteoblasts,  which  are  few  in 
number,  but  no  production  of  osteoid  tissue  devoid  of  lime-salts  such  as 
occurs  in  rickets  (Schmorl).''  The  bone  which  is  formed  is  of  normal 
character.  The  bone-marrow  is  altered  in  nature.  It  loses  its  lymphoid 
elements,  and  the  cells  are  reduced  in  number,  and  in  place  is  found  a 
somewhat  homogeneous  reticulated  substance  containing  few  blood- 
vessels. These  changes  are  most  marked  at  the  ends  of  the  diaphyses. 
Separation  of  the  epiphyses  may  occur  in  severe  cases  as  a  result  of  slight 
trauma,  but  is  uncommon.  The  most  characteristic  lesion,  however, 
consists  in  the  occurrence  of  hemorrhage  depending  upon  weakness  of 
the  blood-vessel  walls.  This  is  always  present  beneath  the  periosteum, 
oftenest  in  the  bones  of  the  lower  extremities  but  frequently  elsewhere 
as  well  (Fig.  210).  Hemorrhage  may  take  place,  too,  in  various  other 
tissues  of  the  body.  It  is  liable  to  be  observed  in  the  muscles  and  skin 
about  the  periosteal  lesion,  or  in  the  neighborhood  of  the  joints,  produc- 
ing a  large,  tender  swelling,  easily  recognized  during  life.  Small  hemor- 
rhages may  occur  in  any  of  the  serous  or  mucous  membranes,  often  from 
the  kidneys,  sometimes  from  the  stomach  or  intestine,  or  in  the  internal 
organs  and  bone-marrow.  The  connnonest  seat  of  hemorrhage  next  to 
that  of  the  periosteum  is  the  mucous  membrane  of  the  gums,  especially 
about  the  upper  incisor  teeth.     Considerable  attention  has  been  directed 

1  Die  Vitamine,  1914. 

2  Zeit.  f.  Heilk.,  1912,  LXXII,  1. 

3  Virchow's  Archiv,  1912,  CCVIII,  367. 

4  Frankfurter  Zeit.  f.  Patholog.,  1913,  XIV,  1. 

5  Zeit.  f.  Heilk.,  1912,  LXXII,  121. 

«  Bost.  Med.  and  Surg.  Journ.,  1913,  CLXIX,  232. 

'  Beitrage  z.  path.  Anat.  u.  z.  allg.  Path.,  1901,  XXX,  232. 


SCORBUTUS  605 

to  the  "white  Hne"  first  described  by  FrankeP  existing  in  x-ray  plates 
at  the  junction  of  the  epiphj^ses  and  diaphj-ses  in  the  long  bones  in  cases 
of  scurv}'.  In  the  print  the  hne  of  course  is  black.  It  would  appear  to 
be  a  reliable  diagnostic  sj'mptom  (Figs.  211  and  212). 

Symptoms. — Although  anemia,  loss  of  appetite,  and  irritabiUty 
usualh'  precede  the  more  characteristic  symptoms,  the  first  manifestation 
observed  in  most  cases  is  pain  in  the  limbs.  This  was  reported  present  in 
314  of  the  379  cases  of  the  American  Pediatric  Society's  series,  in  all  but 
3  of  these  being  in  the  lower  extremities,  either  alone  (149  cases)  or 
combined  with  pain  elsewhere.     It  often  develops  so  suddenly  in  infants 


Fig.  _'1il  i;  imwcjraph  of  Subperiosteal  Lesions  in  Infantile  Sclkvy. 
Child  of  11  inoutlLs,  admitted  to  the  Children's  Hospital  of  Philadelphia,  Jan.  25.  Well 
until  3^  months  previously,  when  pain  and  tenderness  without  swelling  developed  in  the 
left  thigh.  A  month  later  the  right  side  became  tender  and  swollen,  and  has  continued  .so. 
Condition  had  been  supposed  to  be  sarcoma.  Radiograph  (viewed  postero-anteriorly) 
shows  decided  swelling  about  the  right  femur,  and  beginning  involvement  of  the  left. 
Orange-juice  given  freely.     Discharged,  entirely  well. 

who  have  appeared  perfectly  well,  that  it  may  be  attributed  by  the  parents 
to  some  accident.  In  other  cases  the  onset  is  slower,  the  pain  at  first 
being  intermittent,  and  the  child  often  passing  a  numl)er  of  days  at  a  time 
in  entire  comfort.  But  in  all  severe  cases  the  pain  soon  becomes  constant, 
the  tenderness  intense,  and  the  slightest  attempt  at  passive  movement 
occasions  loud  outcries.  AMicn  the  localization  can  be  determined,  it 
is  found  oftenest  in  the  neighl)orhoo(l  of  the  ankles  or  knees.  Even  ap- 
proach to  the  bed-side  may  cause  the  infant  to  scream  through  fear  of 
being  touched.  In  the  majority  of  cases  there  is  suffering  only  when  the 
limbs  are  moved.  In  91  of  the  American  Pediatric  Society's  series,  how- 
'  F'orischr.  uus  d.  (Icbicto  dcr  Rontgenstniliicii,  I'.MXi,  .\,  1. 


606 


THE  DISEASES  OF  CHILDREN 


ever,  pain  was  reported  present  even  when  the  infant  was  entirely  at  rest. 
In  nearly  all  instances  some  degree  of  pseudoparydysis  exists,  depend- 
ent upon  pain,  and  in  some  cases  the  legs  may  b(^  kept  so  still  that  polio- 
myelitis or  other  form  of  paralysis  is  suspected.  The  absence  of  motion 
may  range  from  mere  disinclination  to  move  the  limbs  up  to  complete 
disability;  varying  with  the  case.     At  times  this  is  the  first  symptom 


Fig.  211. — Infantile  Scurvy.     White  Line. 
Subacute  case  in  au  infant  admitted  to  the  Children's  Hospital  of  Philadelphia,  aged 
10  months.     Knees  swollen;  tibise  tender  on  pressure;  moves  the  legs  very  little;  gums 
swollen  and  mottled.     Radiograph  taken  Jan.    17  shows  the  "white  line,"  (in  the  nega- 
tive; naturally  black  in  the  print.) 

noticed  (36  of  the  American  Pediatiic  Society's  series).  Thoracic  pain 
is  sometimes  produced  by  lifting  the  child  in  the  ordinary  manner. 
About  the  same  time  with  the  development  of  pain  the  characteristic 
affection  of  the  gums  develops.  It  was  seen  in  313  cases  in  the  American 
Pediatric  Society's  series  and  was  the  first  symptom  in  42  cases.  It 
consists,  when  well  developed,  in  a  deep  bluish-purple,  spongy  swelling 


Fig.  213. — Ixfaxtile  Scurvy. 

Infant  of  8  niontlis.  Wfll  nourished.  Fed  upon  Horlirk's  Malted  Milk.  Fretful,  ner- 
vous, pain  in  the  l('t;s.  Had  boon  suffering  for  3  weeks.  Recovered  in  3  days.  Illustration 
shows  the  swollen,  purple  gums  about  the  upper  incisors,  and  the  purple  streaks  in  the  gums 
of  the  lower  jaw. 


SCORBUTUS 


607 


of  the  mucous  membrane,  generally  over  the  upper  incisior  teeth,  some- 
times so  decided  that  the  teeth  become  entirely  concealed  (Fig.  213). 
Slight  hemorrhage  from  the  gums,  or  from  the  palate  or  pharynx  takes 
place  readily  and  ulceration  is  not  infrequently  present.  As  a  rule  the 
involvement  of  the  gums  occurs  only  in  infants  whose  incisor  teeth  have 
already  erupted,  but  this  is  because  the  disease  is  seen  so  much  oftener  in 


• 


Fig.  212. — Infantile  Scurvy.     A\  mitk  Lim;. 
Same  case  as  in  Fig.  211.     Radiograph  made  Feb.  11.     Treatment  witli  urange-juiic 


was  instituted,  and  symptoms  were  proniptly  relieved, 
ance  of  the  "white  line  " 


Radiograph  shows  the  disappear- 


those  past  the  age  of  the  first  appearance  of  teeth.  In  45  cases  in  the 
American  Pediatric  Society's  series  no  teeth  had  been  cut  and  in  24  of 
these  the  gums  were  affected.  Often  at  this  time  sirelling  along  the  shaft 
of  the  long  bones  can  be  found.  This  is  hard  and  tender  and  is  situateil 
usually  in  proximity  to  a  joint,  oftenest  {hv  ankle  or  the  knee,  but  docs  not 
involve  it.     The  swelling  may  be  bilateral,  with  the  skin  over  it  shining 


608  THE  DISEASES  OF  CHILDREN 

but  usuallj'  not  reddened  (Fig.  214).  It  may  be  only  slight,  but  is  not 
infrequently  extensive,  increasing  greatly  the  general  size  of  the  limb. 
In  severe  cases  the  affected  limb  may  become  extensively  edematous. 
Quite  often  hemorrhages  in  the  form  of  ecchymoses  or  petechias  are  seen 
elsewhere  in  various  regions  of  the  cutaneous  surface  (182  of  353  cases  in 
the  American  Pediatric  Society's  series).  They  may  be  widespread  and 
may  be  found  also  on  the  mucous  membrane  of  the  mouth  and  pharynx; 
sometimes  upon  the  conjunctivae.  They  are  often  among  the  earliest 
evidences  of  the  disease.  Orbital  hemorrhage  occurs  in  a  rather  small 
proportion  of  cases  (49  of  the  American  Pediatric  Society's  series)  pro- 
ducing purplish  swelling  of  the  eyelids  and  protrusion  of  the  eyeball. 
In  severe  cases  blood  may  be  vomited  or  passed  by  the  bowel. 
Hemorrhage  from  the  kidney,  usually  slight,  is  commoner  than  usually 
supposed,  its  frequency  not  depending  upon  the  severity  of  the 
case.     I    have    known    it    to    be    the    only    positively    characteristic 


Fig.  214. — Infantile  Scurvy,  Showing  Swelling  of  Legs. 
Infant  of  1 3^2  months,  in  the  Children's  Ward  of  the  University  Hospital,  Philadelphia. 
Been  fed  on  proprietary  food.     Pain  and  swelling  in  both  legs  and  about  the  knees.     Right 
arm  also  involved.     Improved  on  orange-juice,  but  died  of  diarrheal  disorder. 

symptom  in  otherwise  doubtful  cases,  ^  and  have  observed  it  present 
in  probably  the  majority  of  cases  where  the  urine  has  been  examined. 
Blood-casts  and  granular  casts  may  occur.  The  loss  of  blood  may  some- 
times be  discoverable  only  by  microscopical  examination;  in  other  in- 
stances the  urine  is  distinctly  red  or  smoky.  Albuminuria  independent 
of  the  loss  of  blood  is  not  infrequent. 

In  the  meantime  the  general  condition  of  the  child  suffers.  In  severe 
cases  there  is  a  progressive  wasting  accompanied  by  the  development  of 
a  cachectic  appearance  and  one  expressing  the  constant  presence  of  pain. 
The  infant  lies  almost  motionless  and  may  cry  almost  continuously  and 
sleep  but  little,  and  its  condition  is  most  wretched.  There  may  be  mod- 
erate fever.  The  heart  is  weak,  the  appetite  diminished,  and  the  stools 
often  diarrheal  or  constipated.  Anemia  is  little  marked  at  first,  but 
becomes  decided  as  the  disease  advances,  being  a  secondary  anemia  with 
especial  reduction  of  the  hemoglobin  as  compared  with  that  of  the  red 
cells  and  with  a  moderate  and  inconstant  leucocytosis.  Hess  and  Fish^ 
found  the  coagulability  of  the  blood  slightly  diminished,  but  not  to  any 
noteworthy  degree. 

Complications. — ^By  far  the  most  frequent  is  rickets,  and  the 
association  of  this  with  scurvy  is  so  common  that  a  necessary  connection 

iPhila.  Med.  Journ.,  1901,  Feb.  2. 

2  Amer.  Journ.  Dis.  Child,  1914,  VIII,  386. 


SCORBUTUS  609 

has  been  supposed.  This,  however,  does  not  appear  to  exist,  and  the  two 
diseases  are  entirely  independent.  In  45  per  cent,  of  340  cases  of  scurvy 
in  the  American  Pediatric  Society's  series  it  was  distinctly  stated  that  rick- 
ets was  not  present,  and  even  admitting  that  slight  rickets  may  have  been 
overlooked  in  some  of  these,  it  is  certainly  improbable  that  it  was  so  in 
all.  Bronchopneumonia  or  gastroenteric  disturbances  are  occasionally 
fatal  complications. 

Course  and  Prognosis. — The  prognosis  is  excellent  in  cases  promptly 
treated,  and  recovery  is  very  rapid.  All  pain  ceases  in  a  week  or  less. 
There  is  scarcely  another  disease  in  which  the  results  of  treatment  are 
so  rapid  and  remarkable.  The  swelling  of  the  bones  and  the  constitu- 
tional symptoms  disappear  within  2  or  3  weeks  even  in  severe  cases,  unless 
some  serious  complication  be  present.  If  untreated,  however,  the  disease 
is  chronic,  the  symptoms  gradually  becoming  more  marked  and  the  gen- 
eral condition  constanth^  worse  and,  although  spontaneous  recovery  may 
eventually  take  place  in  the  mild  cases,  death  is  liable  to  occur  in  the 
severer  ones  from  malnutrition,  exhaustion,  or  some  intercurrent  disease 
after  a  period  of  several  months. 

Diagnosis. — Although  the  disease  is  usually  readily  recognized  by 
those  familiar  with  it,  it  is  the  source  to  others  of  numerous  errors.  The 
failure  to  make  a  diagnosis  nearly  always  depends  not  upon  any  difficulty 
attending  it,  but  upon  the  fact  that  the  possibility  of  the  existence  of 
scurvy  has  not  occurred  to  the  observer.  The  diagnosis  in  typical  cases 
rests  upon  the  combination  of  great  pain  and  tenderness  of  the  limbs,  with 
swelling  and  hemorrhage  beneath  the  periosteum  and  in  the  gums  and 
elsewhere.  In  general  it  is  safe  to  assume  that  pain  in  the  limbs  and 
pseudoparalysis  developing  rapidly  in  an  infant  between  4  months 
and  2  years  of  age  is  due  to  scurvy,  unless  examination  reveals  other 
causes,  even  although  no  affection  of  the  gums  is  discoverable. 

The  diagnosis  of  rheumatism  is  the  one  oftenest  falsely  made.  This 
disease,  however,  is  exceedingly  rare  in  infancy.  When  present  it  affects 
the  joint  and  not  the  bone;  there  is  no  involvement  of  the  gums,  and  the 
employment  of  anti-scorbutic  treatment  is  nefficacious.  The  pseudo- 
parah'sis  of  syyhilis  may  suggest  scurvy.  It  occurs,  however,  usually  at 
an  earlier  age,  produces  less  tenderness,  is  oftener  limited  to  the  arms,  is 
always  situated  at  the  epiphyseal  junction  and  not  in  the  shaft  of  the  bone, 
and  is  associated  with  other  symptoms  of  syphilis.  When  epiphyseal 
separation  occurs  in  scurvy,  the  other  symptoms  of  the  disease  are  so 
well  marked  that  mistakes  in  diagnosis  can  hardly  occur.  Poliomijelitis 
is  sometimes  suggested  by  scurvy  on  account  of  the  apparently  flaccid 
paralysis  of  the  legs.  There  is,  however,  in  scurvy  far  more  tenderness 
present  and  no  alteration  of  the  electrical  reactions.  OsteomijcUtis 
invades  the  joints,  if  it  does  not  l)egin  there,  and  is  attended  by  fever 
and  pyemic  constitutional  symptoms  cjuite  (UlTerent  from  those  of  scurvy. 
The  painful  immol)iHty  of  the  Hmbs  of  scurvy  may  suggest  hip-joint 
disease  or  sometimes  (lisease  of  the  spine,  or  the  sweHing  may  be  mis- 
taken for  that  of  a  malignant  growth  of  the  bone.  The  freciuent  presence 
of  rachitis  as  a  complication  leads  sometimes  to  the  overlooking  of  the 
existence  of  scurvy  also.  There  is,  however,  no  hemorrhagic  tendency  in 
rickets,  and  imin-ovement  under  dietetic  treatment  is  slow.  The 
hemorrhagic  rickets  of  earlier  writers  is  in  reality  scorbutus. 

Treatment.  Prophylaxis  conssts  in  the  avoidance  of  diet  known  to 
predispos(>  to  the  (lcvcl()i)iiiciit  of  the  disease.  Inasmuch  as  there  seems 
reason  to  believe  that  the  heating  of  milk,  and  especially  the  iMuploynient 


610  THE  DISEASES  OF  CHILDREN 

of  proprietary  foods,  predisposes,  the  administration  of  fruit-juices  should 
"begin  early.  The  pasteurization  of  the  food  is  generally  so  important  a 
matter  that  it  should  never  be  avoided  merely  on  account  of  the  possi- 
bility of  scurvy  developing.  The  evils  which  threaten  to  follow  the  inges- 
tion of  raw  milk  not  of  the  very  best  quality  are  far  greater  and  much  more 
dangerous  than  those  produced  by  scorbutus,  and  the  latter  are  readily 
prevented. 

Treatment  of  the  Attack. — This  consists  primari  y  in  correcting  the 
diet.  In  some  cases  the  mere  change  from  a  cooked  milk-mixture  to  one 
of  raw  milk  is  sufficient.  In  others  the  abandoning  of  a  proprietary  food 
answers.  When  scurvy  appears  the  change  in  diet  should  always  be 
made  promptly  unless  there  is  some  reason  against  this.  On  various 
grounds,  however,  it  may  seem  inadvisable  to  make  any  sudden  alteration 
in  a  diet  which  has,  in  other  respects,  been  found  satisfactory.  Fortu- 
nately we  have  almost  a  specific  for  the  disease  in  fresh  fruit-juice,  and  this 
should  a'ways  be  administered.  Orange-juice  is  one  of  the  best,  the  juice 
of  one-half  and  later  of  one  orange  of  average  size,  sweetened,  being  given 
either  in  divided  portions  or  in  a  single  dose,  usually  between  feedings. 
Diarrhea,  if  present,  offers  no  contra-indication,  and  may  even  be  con- 
trolled by  the  treatment.  The  only  fatal  case  I  have  seen  was  one  in 
which  orange  juice  was  mistakenly  avoided  on  account  of  the  presence  of 
intestinal  disturbance.  Freshly  expressed  beef-juice  is  also  of  service, 
but  not  to  so  great  a  degree.  For  children  over  1  year,  or  even  somewhat 
younger,  potato  or  other  fresh  vegetables  may  be  given  with  advantage. 
If  the  diet  is  for  any  reason  not  altered  immediately,  the  change  should 
certainly  be  made  as  soon  as  possible  in  order  to  prevent  a  recurrence  of 
the  disease.  Should  the  anemia  and  debility  not  disappear  promptly 
iron  or  cod-liver  oil  may  be  needed  later.  Of  course  the  infant  must  be 
handled  with  the  greatest  care  while  the  tenderness  remains. 


CHAPTER  III 

INFANTILE  ATROPHY 
(Marasmus.     Athrepsia) 

This  title,  probably  first  employed  by  Soranio  in  the  16th  century 
(Albarcl)  ^  denotes  a  progressive  and  final  y  extreme  wasting  of  the  infant 
without  other  symptoms  or  discoveraf)le  anatomical  lesions  to  account  for 
it.  The  term  "athrepsia  "  was  applied  to  it  by  Parrot.-  From  this  primary 
atrophy  must  be  distinguished  all  cases  of  secondary  atrophy  the  result  of 
malnutrition  dependent  upon  starvation,  congenital  syphilis,  tuberculosis, 
or  evident  chronic  disorders  of  the  gastro-enteric  tract.  This  leaves  the 
term  infantile  atrophy  certainly  useful,  since  the  condition  is  common, 
but  unsatisfactory,  since  many  cases  so  designated  are  undoubtedly  due 
to  positive  but  unrecognized  anatomical  causes.  The  title  to  a  large 
extent  covers  the  condition  designated  ''decomposition"  by  Finkelstein 
(see  p.  698),  applied  to  those  cases  in  which  the  lack  of  power  of  digestion 
and  assimilation  finally  reaches  a  point  at  which  the  infant  fails  to  gain 
no  matter  what  the  diet  may  be.     Whatever  the  cause  of  infantile 

1  Ann.  de  m6d.  et  de  chir.  inf.,  105,  IX,  1. 

2  Prog,  med.,  1874,  II,  637. 


INFANTILE  ATROPHY  611 

atrophy  may  be,  it  is  evident  that  the  condition,  like  icterus,  is  a 
symptom  rather  than  a  disease. 

Etiology. — The  disorder  is  seen  chiefly  in  infants  under  1  year  Hving 
under  bad  hygienic  conditions  in  cities  and  fed  artificiaUy.  It  is  the 
cause  of  many  deaths  in  asylums  for  infants  and  in  crowded  hospital 
wards,  where  the  title  "hospitalism"  has  often  been  well  appHed  to  it. 
Some  gastroenteric  affection  frequently  precedes  it  It  has  been  claimed 
to  depend  upon  an  infection  of  unknown  nature,  but  of  this  there  is  no 
proof  offered.  Another  theory  (Baginsky),^  assumed  an  anatomical 
basis,  the  lesions  being  a  destructive  change  in  Lieberkiihn's  follicles, 
especially  in  Paneth's  cells  (Bloch).-  The  presence  of  any  anatomical 
lesions  has,  however,  not  been  confirmed  by  most  investigators.  That 
the  disease  is  not  dependent  upon  the  absence  in  the  artificial  food  of 
ferments  natural  to  human  milk  is  indicated  by  the  frequency  with  which 
infants  thrive  who  are  fed  entirely  artificially.  The  prevaihng  view 
makes  primary  infantile  atrophy  a  defect  in  the  physiological  processes 
of  the  organism,  as  a  result  of  which  the  infant  cannot  utilize  the  food 
given ;  this  depending  either  upon  disturbance  of  the  intestinal  secretions, 
including  ferments,  or  upon  faulty  metaboHsm  causing  a  loss  of  power  of 
assimilation  in  the  tissues  themselves.  According  to  the  former  view, 
the  intestinal  ferment  is  absent  which  completes  the  breaking  down  of 
foreign  (cow)  protein  and  the  reconstruction  of  the  homologous  protein 
which  the  infant  can  properly  utilize.  In  the  latter  theory  may  perhaps 
be  included  the  suggestion  that  an  acidosis  or  some  other  intoxication 
develops  and  acts  as  a  determining  cause  through  the  poisoning  of  the 
system.  It  has  also  been  ma  ntained  that  the  imperfect  metabolism 
depends  upon  defective  internal  secretions.  The  presence  of  diminution 
in  the  size  of  the  thymus  gland,  for  instance,  has  been  pointed  out  by 
several  observers  (Mettenhcimer)^  (Stokes,  Ruhrahand  Royal)^asaccom- 
panj'ing  atrophic  conditions  in  infancy.  No  etiological  relationship,  how- 
ever, has  been  proven.  Whatever  the  influence  of  any  of  the  causes 
mentioned  may  be,  they  are  in  any  event  not  the  primary  or  sole  factor. 
In  the  large  majority  of  instances  there  has  early  been  some  long-con- 
tinued defect  in  the  diet,  which  has  finally  resulted  in  an  inability  on  the 
part  of  the  infant  longer  to  utilize  the  food  given  to  it.  Very  defective 
hygiene  is  another  influential  factor,  especially  confinement  in  illy-ven- 
tilated rooms  in  the  poorer  pai-ts  of  the  cities,  or  the  occupying  of  crowded 
institutions  for  infants.  It  is  on  this  account  that  the  disease  is  com- 
paratively uncommon  in  country  practice,  or  in  civic  practice  among  the 
better  classes.  A  further  cause  often  of  importance  is  the  presence  of  a 
constitutional  del)ility,  whether  due  to  prematurity  or  to  ill-health  of  the 
parents. 

Pathological  Anatomy. — ^Any  lesions  found  must  be  reganled  only 
as  secondary.  Fatty  changes  in  the  liver  arc  often  seen,  but  no  more 
freciucntly  than  in  many  other  disorders  in  infancj'.  Bronchitis,  broncho- 
lineumonia,  atalcctasis,  hypostatic  pulmonary  congestion,  and  intestinal 
derangements  are  also  o'ten  observed,  and  may,  as  complications,  iiave 
precipitated  the  fatal  ending.  The  lymphatic  glands  are  .sDuietimes 
enlarged.  Atrophy  of  the  mucous  membrane  of  the  intestine  may  be 
present  but  appears  to  be  the  result  of  the  general  atrophy  of  the  soft 
tissues  of  the  l)ody,  and  is  frequently  entirely  absent. 

1  Brit.  M<m1.  .Tourn.,  1809,  I,  1()S4. 
2.1:ilirl).  I".  Kiiulcrli.,  lOOC),  LXIIl,  421. 
3.1:ihrl).  f.  Kinderh..  ISOS,  XJAI.  .").■). 
*  Aincr.  .loiini.  .Med.  Sri.,  1<K)J.  Nov. 


612 


THE  DISEASES  OF  CHILDREN 


Symptoms. — The  essential  sj-mptom  is  progressive  loss  of  weight. 
The  emaciation  finally  becomes  excessive,  the  face  wrinkling  all  over  with 


Fig.  215. — Infantile  Atrophy. 
From  a  patient,  aged  7  weeks,  in  the  Children's  Hospital  of  Philadelphia.     Had  been 
boarded  out  since  birth.     Temperature  95°  to  98°F.    (35°  to  36.7°C.).     2  to  3  soft  stools 
daily.     Death. 


Fig.  216. — Infantile  Atrophy. 
Child  of  4  months,  admitted  to  the  Children's  Hospital  of  Philadelphia,  weighing  6 
pounds, 4  ounces  (2835).      Been  fed  on  condensed  milk  and  various    fresh-milk  mixtures. 
Progressive  loss  of  weight.     No  active  digestive  disturbance  until  within  2  weeks. 


Fig.  217. — Infantile  Atrophy. 
Same  infant  as  in   Fig.  216,  taken  2  months  later,  weighing    10  pounds  (4536),  after 
careful  dietetic  and  other  treatment. 

each  feeble  cry,  giving  the  infant  the  expression  of  a  withered  old  man  (Fig. 
21.5,  216  and  217).     The  fontanelle  is  depressed  and  unusually  small; 


INFANTILE  ATROPHY 


613 


the  bones  of  the  skull  overlap;  the  chin  and  cheek-bones  are  prominent; 
the  eyes  large  and  sunken;  the  skin  of  the  body  is  pale  and  hangs  in  loose 
wrinkled  folds.  The  arms  and  legs  seem  to  consist  of  bones  with  only  a 
thin  layer  of  skin  over  them;  the  hands  are  like  claws  and  they  and  the 
feet  cold  and  cyanosed.  The  outlines  of  the  collar  bones  and  the  ribs 
suggest  a  washing-board.  The  abdomen  is  sometimes  very  prominent; 
sometimes  sunken  with  the  thin  skin  over  it  showing  dilated  veins  and 
revealing  the  outlines  of  the  in- 
testines beneath.  The  temperature 
is  usualh'  subnormal  (Fig.  218), 
the  respiration  superficial,  the 
circulation  poor,  more  or  less  anemia 
is  present,  and,  toward  the  end  of 
life,  edema  also,  especially  of  the 
face  and  extremities,  but  sometimes 
of  the  whole  surface.  At  this  period 
a  gain  in  weight  may  give  false  en- 
couragement. It  is,  however,  a  bad 
sj'mptom,  due  to  the  deposit  of  liquid 
in  the  tissues.  The  appetite  is 
usually  diminished,  sometimes 
voracious;  the  stools  are  often 
regular  and  well  digested,  oftener 
contain  mucus  and  undigested  food. 
Yet  no  matter  how  normal  the 
stools,  the  loss  of  weight  continues. 
Vomiting  occurs  easily;  albuminuria 
is  absent.  The  infant  is  at  first 
fretful  and  cries  often;  later  apa- 
thetic and  lying  with  little  move- 
ment. The  muscles  are  usually 
flabby  and  relaxed,  but  in  some 
cases  a  condition  of  hypertonia  is 
observed,  producing  arching  of  the 
back,  retraction  of  the  head,  and 
flexion  of  the  thighs  upon  the  abdo- 
men. (See  Vol.  II,  p.  254. )  The  whole 
aspect  is  one  of  the  most  shocking  in 
the  realm  of  pediatrics.  The  infant 
appears  to  bo  merely  a  skeleton  with 
a  thin  covering  of  skin. 

Complications.  —  Infantile 
atrophy  is  often  complicated  by 
the  development  of  furunculosis  and 
other  cutaneous  abscesses;  erythema 
chiefly  of  the  nates,  scrotum,  and 
back  of  the  thighs;  hernia;  and  thrush.  Petechia',  especially  on  tlie  ab- 
domen, often  develop  shortly  before  death.  (See  Vol.  II,  p.  477,  Fig.  3!M)). 
Bronchopneumonia,  atelecta.sis,  and  gastrointestinal  derangements  are 
frefjuent.     Convulsions  may  terminate  the  scene. 

Prognosis. — This  is  always  grave  and  the  majority  of  well-established 
cases  die  after  weeks  or  months  of  wasting,  in  spite  of  the  greatest  care. 
The  disease  steadily  grows  worse,  or  in  some  cases  exliibits  temporary 
periods  of  arrest  of  loss  of  weight  or  even  a  slow  gain,  to  he  followed  by 


Fig.  21.S. — Inf.^ntile  Atruphy,  with 
Hypothermia  and  Terminal  Increase 
OF  Temper.\ti;re. 

Robert  M.,  aged  3  months.  Said 
to  have  been  vomiting  more  or  less  since 
age  of  3  weeks.  Bottle  fed.  Last  2 
weeks  some  retraction  of  head.  Entered 
in  the  University  Hospital  in  Philadelphia, 
Oct.  4,  cries  a  great  deal,  much  cniaciatod, 
no  vomiting  since  admission,  stools 
normal.  No  improvement.  Death. 
Autopsy  findings  negative. 


G14  THE  DISEASES  OF  CHILDREX 

sudden,  rapid  renewed  loss.  The  reduction  of  the  amount  of  food  taken, 
on  the  ground  that  some  digestive  disturbance  is  present,  is  followed  by 
increased  loss  of  weight;  and  the  same  happens  if  the  quantity  is  aug- 
mented. In  fact,  marantic  infants  are  extremely  susceptil)le  to  changes 
in  the  nourishment,  and  may  be  made  rapidly  worse  by  this.  Death 
may  occur  quite  unexpectedly  from  causes  not  ascertainable,  the  infant 
being  perhaps  found  dead  in  bed,  although  when  last  seen  it  was  appar- 
ently no  worse  than  usual.  In  othercases  some  complication,  often  of 
very  slight  severity,  is  the  cause  of  rapid  failure  of  strength  and  of  a  fatal 
ending.  The  sudden  development  of  hot  weather  precipitates  the 
termination.  Yet  under  favorable  circumstances  a  certain  number  of 
cases  can  be  saved.  The  longer  the  condition  has  lasted  and  the  older 
the  infant,  the  greater  the  prospect  of  cure.  Recovery  may  be  slow  but 
finally  complete  (Fig,  217),  and  the  child  in  later  years  may  appear  no 
worse  for  the  illness  of  infancy. 

Diagnosis. — The  condition  does  not  differ  in  symptomatology  from 
the  secondary  atrophy  dependent  upon  starvation,  tuberculosis,  or  other 
cause,  and  the  object  of  diagnosis  is  to  exclude  these  factors.  This  is  at 
times  most  difficult.  The  existence  of  tuberculosis  may  become  evident 
only  at  autopsy.  In  other  cases  the  presence  of  the  tuberculin  reaction 
or  the  discovery  of  some  localized  symptoms  indicate  tuberculosis.  A 
coincidence  of  the  date  of  the  commencement  of  failing  health  with  that 
of  weaning  or  some  other  change  of  diet  suggests  marasmus.  Starvation 
from  mere  lack  of  sufficiently  nourishing  food  is  readily  differentiated 
by  the  rapid  improvement  which  follows  a  proper  diet. 

Treatment. — In  the  way  of  prophylaxis  the  continuance  of  breast- 
feeding in  whole  or  in  part,  or,  when  this  is  not  possible,  the  careful  avoid- 
ance of  digestive  disturbances,  accomplished  by  a  judicious  selection  of 
cow's  milk  mixtures  is  of  great  value,  as  is  the  obtaining  of  an  abundance 
of  fresh  air  and  the  avoidance  of  excessive  summer  heat.  For  the  fleveloped 
condition,  dietetic  measures  are  of  much  service,  yet  these  can  l)e  but  ex- 
perimental as  long  as  the  nature  of  the  cause  is  not  understood.  The 
employment  of  a  suitable  wet-nurse  is  greatly  to  be  desired,  in  fact  is 
almost  imperative,  although  it  by  no  means  follows  that  life  can  be 
saved  in  this  way.  When  it  is  impossible  to  feed  otherwise  than  artifi- 
cially, the  same  rules  hold  good,  and  the  same  difficulties  obtain,  as 
attend  the  treatment  of  indigestion.  (See  p.  767.)  C'are  must  l)e  taken 
in  advanced  cases  to  avoid  any  prolonged  starvation-treatment,  such  as 
would  be  properly  employed  in  acute  digestive  disturbances.  The 
strength  of  the  infant  is  not  sufficient  to  tolerate  this  well.  On  the  other 
hand,  the  initial  food  should  be  of  only  such  a  caloric  strength  as  would, 
under  normal  conditions,  maintain  the  weight,  without  effort  to  increase 
it.  More  than  this  cannot  be  hoped  for  at  the  beginning.  The  food 
should  be  weak,  given  frequently  and  in  small  amounts.  As  regards  the 
selection  of  the  nourishment,  the  principles  apply  which  are  operative  in 
the  treatment  of  chronic  digestive  diseases  (pp.  723,  763).  In  general 
protein-foods  such  as  buttermilk  and  casein  milk  offer  the  best  of  the  un- 
fortunately often  slim  chances  for  success.  Dextrin-maltose  prepara- 
tions and  saccharose  are  usually  preferable  to  lactose.  Weak  cereal 
decoctions  may  sometimes  be  of  benefit.  Fat  is  generally  better  avoided 
or  given  in  very  small  amount;  although  it  sometimes  happens  that 
cream-whey  mixtures  are  certainly  of  value. 

In  cases  where  wasting  is  great  and  the  need  of  liquid  in  the  tissues 
evident,  hypodermoclysis  may  often  be  used  with  advantage.     Freeman' 

'  Arch,  of  Ped.,  1917,  XXXIV,  428. 


MALNUTRITION  615 

claimed  good  results  from  the  subcutaneous  injection  of  horse-serum,  and 
Dunn/  from  the  introduction  of  a  5  per  cent,  solution  of  dextrose  into 
the  longitudinal  sinus ;  giving  of  the  solution  \^q  of  the  body-weight.  This 
supplies  the  infant  with  much  needed  nourishment  as  well  as  with  liquid. 

Of  great  importance  is  the  obtaining  of  fresh  air.  The  disease  dimin- 
ishes in  hosiptal  practice  in  proportion  as  the  air-space  of  the  room  is 
increased,  and  especially  through  the  use  of  open  sun-parlors  or  roof- 
gardens,  unless  the  presence  of  unusually  low  body-temperature  precludes 
this.  In  fact  in  hospital-practice  one  of  the  best  plans  of  treatment  is 
to  send  the  child  with  beginning  hospitalism  home,  if  it  can  be  taken  care 
of  there  in  a  manner  at  all  suitable.  The  fact,  however,  is  too  often 
evident  that  the  bad  hygienic  conditions  of  the  home  are  even  worse  than 
the  retention  of  the  infant  in  the  hospital. 

General  massage  with  oil  is  of  value  in  many  instances.  Alcoholic 
stimulants  in  moderate  dose  are  serviceable  if  the  fontanelle  is  much 
depressed  and  the  general  circulation  poor.  Should  the  temperature  of 
the  body  be  below  normal  it  must  be  maintained  by  the  employment  of 
hot  water-bottles.  In  the  case  of  young  infants  with  threateningly  low 
temperature  it  is  best  to  confine  the  patient  to  a  suitable  warm  room, 
which  must,  however,  receive  sufficient  previously  warmed  fresh  air. 


CHAPTER  IV 
MALNUTRITION 


By  the  general  and  rather  vague  term  Malnutrition  we  may  cover 
all  the  secondary  atrophies  and  instances  of  failure  to  gain  in  weight, 
independent  of  whether  the  causes  are  organic  or  functional;  reserving  the 
title  "Infantile  Atrophy"  or  "Marasmus"  for  the  severe  cases  with  the 
etiology  and  symptomatology  as  described  in  the  previous  chapter.  The 
term  Inanition,  literally  "emptiness,"  may  be  regarded  as  expressing  an 
unusual  degree  of  malnutrition,  in  reality  dependent  upon  a  starvation. 
The  distinction  is,  however,  usually  not  very  sharply  drawn. 

Etiology. — Malnutrition  is  extremely  common,  and  depends  upon 
various  causes.  A  constitutional  debility  may  be  present  in  children 
from  the  time  of  birth,  and  render  them  always  below  normal  in  their 
strength,  weight,  and  resisting  power  to  disease  of  any  sort.  Many  cases 
of  premature  birth  are  to  be  placed  in  this  category.  Children  with  a 
congenital,  excessively  nervous  development  constitute  a  considerable 
proportion  of  the  instances  of  malnutrition  in  childhood.  Not  only  may 
tuberculosis  and  syphilis  of  the  parents  produce  a  state  of  malnutrition 
in  the  offspring,  which,  however,  may  not  show  evidences  of  the  existence 
of  either  of  these  diseases,  but  parents  delicate  or  diseased  from  any  cause 
may  be  unfit  to  produce  children  capable  of  thriving  normally. 

In  prol)ably  the  majority  of  cases,  however,  the  condition  is  not  a 
constitutional  one  observable  at  birth,  but  is  acquired  later,  tiie  infants 
appearing  healthy  when  born.  The  presence  of  chronic  disease  of  any  na- 
ture may  be  the  cause,  to  be  mentioned  here  being  tuberculosis,  syphilis, 
rachitis,  diabetes,  malignant  growths  and  chronic  disturbances  of  any  of 
the  organs  of  the  body,  most  frequently  the  gastroenteric  tract.  Even 
the  occurrence  during  early  infancy  of  an  acute  disorder,  oftenest  digestive 
in  nature,  may  leave  a  chronic  malnutrition  in  its  train.     Continued 

I  Arch,  of  Ped.,  1917,  XXXIV,  425. 


616 


THE  DISEASES  OF  CHILDREN 


improper  or  insufficient  diet  and  the  constant  living  under  bad  hygienic 
conditions  with  lack  of  sufficient  fresh  air  are  perhaps  the  most  frequent 
factors;  and  this  applies  not  only  to  the  children  of  the  poor  to  whom  too 

little  care  is  given,  but  equally  well  to  the  many 
over-housed,  pampered  and  over-cared-for  chil- 
dren of  the  well-to-do.  Finally,  a  more  or 
less  acute  inanition  from  insufficient  food  may 
occur  at  any  period  of  early  life,  but  oftenest 
in  infants.  Here  the  food  may  as  a  whole  be 
ingested  in  much  too  small  an  amount,  either 
because  it  is  too  weak  in  character  or  scanty  in 
quantity,  or  because  the  child  refuses  it;  or  may 
be  sufficiently  strong  in  some  respects  but  very 
deficient  in  others,  and  inanition  result.  In 
other  cases  which  have  suffered  from  some 
long-continued  digestive  disease,  severe  inani- 
tion rapidly  develops  in  consequence  of  the 
curtailing  of  the  amount  of  food  which  was 
intended  to  act  as  a  therapeutic  measure. 

Symptoms. — As  the  name  denotes,  the 
symptoms  of  malnutrition  are  those  of  imper- 
fect nutritional  development.  In  infants  the 
growth  of  the  body  in  weight  and  often  in  length 
as  well  is  much  below  normal.  The  strength  is 
poor;  the  muscles  flabby;  the  child  cannot  sit  or 
stand  at  the  age  when  this  should  normally 
have  been  learned;  evidences  of  digestive  dis- 
turbances are  a  not  infrequent  accompaniment; 
rickets  is  not  uncommon,  although  in  the 
severest  cases  it  is  noteworthy  that  rickets  is 
absent  or  but  little  developed.  The  digestive 
and  assimilative  powers  are  feeble,  and  the 
physician  is  constantly  occupied  by  the  effort  to 
find  a  diet  which  will  be  sufficiently  nourishing 
and  yet  which  will  not  disturb  the  digestion  and 
produce  a  loss  of  weight. 

The  cases  of  acute  inanition  present  symp- 
toms of  interest.     In  many  such,  as  a  result  of 
the  causes  mentioned,  a  very  rapid  and   dan- 
gerous loss  of  weight  takes  place,  often  following 
upon  a  previous  moderate  degree  of  malnutrition, 
sometimes  occurring  rapidly  without  this.     With 
the  loss  of  weight  is    the  development  of  low 
body-temperature  (Fig.  219),  sunken  fontanelle, 
hollowness  about  the  eyes,  pallor,  feeble  pulse, 
and  all  the  signs  of  great  depression  of  strength. 
The  condition  suggests  infantile  atrophy,  but  is 
distinguished     by     the     prompt    improvement 
which  occurs  when  sufficient  proper  nourishment 
is  given,  if  this  has  not  been  too  long  delayed. 
Another  interesting  form  in  infants  is  the  malnutrition  from  excess 
of  starch.     This  appears  to  be  a  common  disorder  in  those  regions,  as 
in  parts  of  Germany,  where  a  diet  largely  of  cereal  decoctions  is  em- 
ployed for  infants  by  the  laity.    It  has  been  designated  Mehlndhrschaden 


O**  cr  moxrm 

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l(. 

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i1 

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TM,, 

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■180 

-170 



-160 

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66- 

-140 

-— 





-110 

-50 

-100 

-^eJ 

— 

44^ 

— 

— 

40- 

— 

38 

-60 

— 



-70- 

■30 



26 

-60 

Z6 



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20 

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1 

Fig.  219  .■ — Inanition 
FROM  Starvation  on 
Greatly  Diluted  Con- 
densed Milk. 

Samuel  S.,  9  weeks  old, 
Jan.  15.  Breast-fed  1 
month,  then  given  y'2 
drachm  condensed  milk  in 
5  ounces  of  water.  Grown 
progressively  weaker.  Now 
very  weak,  slow  pulse  and 
respiration,  subnormal  tem- 
perature, almost  unable  to 
move,  mucous  membranes 
pale,  abdomen  scaphoid, 
child  remains  in  any  position 
placed,  almost  unable  to 
swallow,  fed  by  pipette. 
Death  on  3d  day  after  ad- 
mission to  the  Children's 
Ward  of  the  University 
Hospital,  Philadelphia. 


MALNUTRITION  617 

(Czerny  and  Keller).^  In  the  United  States  it  is  certainly  not  so 
common.  Sometimes  it  follows  the  too  long  continuance  of  an  amy- 
laceous diet,  prescribed  for  infants  who  have  been  suffering  from 
diarrhea  with  inabilit}-  to  digest  milk.  It  is  to  be  noted  that  the  occur- 
rence of  this  form  of  malnutrition  generally  develops  only  when  such  a 
diet  has  been  continued  for  a  considerable  time.  The  temporary  sub- 
stitution of  milk  by  starchy  food  is  a  well-approved  course  of  treatment  of 
some  digestive  disturbances;  but  the  danger  of  the  continuance  must  be 
borne  in  mind.  The  appearance  of  symptoms  would  appear  to  depend 
not  so  much  upon  the  presence  of  the  excess  of  starch  as  upon  the  relative 
deficiency  of  protein  and  of  fat,  the  disease  being  one  of  deprivation. 

Three  types  may  be  recognized:  First  the  hypertonic  form  (see  Vol.  II, 
p.  254)  in  which  there  is  a  rigid  condition  of  the  muscular  system  with  opis- 
thotonos, adduction  of  the  arms  and  thighs,  and  flexion  of  the  forearms 
and  legs.  This  is  the  least  common  variety ;  and  hj^pertonia  may  be  seen 
in  other  nutritional  disturbances  than  those  dependent  upon  a  starchy  diet. 
Second,  an  atrophic  form  which  does  not  differ  much  in  appearance  from 
ordinary  inanition  from  starvation,  although  the  condition  of  hypertonia 
is  often  associated.  In  this  variety  there  has  been  no  addition  of  salt 
to  the  diet.  Third,  the  hydremic  form  in  which  salt  has  been  added  freely 
to  the  food  and  as  a  result  the  water  is  retained  in  the  tissues.  This  re- 
tention of  water  makes  the  infant  at  first  appear  well  nourished,  but 
gradually  the  presence  of  edema  becomes  very  noticeable,  and  the  increase 
in  weight  is  decided.  In  all  forms  the  skin  is  pale  and  of  a  pasty  appear- 
ance, and  the  infant  is  especially  liable  to  the  development  of  infections, 
chief  among  them  being  suppurative  processes  of  the  skin  and  xerosis  of 
the  cornea  and  conjunctiva  with  destruction  of  the  eye  often  following. 

In  older  children  the  symptoms  of  malnutrition  show  themselves  in 
various  ways,  such  as  anemia;  coldness  of  the  extremities;  the  we  ght 
and  often  the  length  being  decidedly  below  normal;  fretfulness;  nervous- 
ness; poor  appetite;  constipation;  coated  tongue;  insomnia;  fatigue  on 
slight  exertion,  the  child  being  unwilling  to  exercise,  or  too  restless  and 
active  and  growing  fatigued  and  irritable  before  evening  comes  on. 
Sometimes  the  children  are  above  the  average  mentality;  sometimes  they 
easily  become  mentally  tired,  and  the  ordinary  school-work  is  difficult 
and  burdensome.  Very  slight  causes  are  liable  to  produce  outbreaks  of 
indigestion.  There  is  very  little  resisting  power  to  attacks  of  disease  of 
any  sort,  illnesses  developing  readily  and  leaving  a  distinct  impression 
on  the  system. 

Course  and  Prognosis. — This  varies  with  the  age  and  with  the 
cause.  Children  who  are  born  constitutionally  predisjwsed  to  malnutri- 
tion cannot  be  expected  to  become  hardy  with  any  rapitlity  if  at  all.  In 
those  in  whom  the  disorder  depends  upon  some  existing  or  previously 
existing  disease,  the  duration  of  the  condition  and  the  ultimate  outcome 
depend  upon  the  nature  of  this  and  the  possibility  of  removing  it  if  still 
present.  Very  often  the  state  of  malnutrition  disappears  to  a  large 
extent  when  later  childhood  is  passed;  in  other  cases  it  is  permanent. 
There  is  always,  too,  the  danger  of  a  fatal  t(M-niination  from  the  occurrence 
of  some  of  the  numerous  comj)li('ating  disorders  to  the  (Un'clopnient 
of  which  the  subjects  of  malnutrition  are  esj)ecially  liable.  The  imme- 
diate^ danger  from  malnutrition  is  nuich  the  greatest  in  young  infants. 
The  older  they  grow  the  greater  the  chance  of  final  recovery,  provided 
proper  therapeutic  measures  can  be  enforced. 

'  Des  Kindes  Ernahrung,  etc.,  1900,  II,  02. 


618  THE  DISEASES  OF  CHILDREN 

In  the  nutritional  disturbances  dependent  upon  an  excessively  starchy 
diet,  the  prognosis  is  very  uncertain,  being  worse  in  proportion  to  the 
youthfulness  of  the  infant,  the  length  of  time  the  faulty  diet  has  been 
employed,  and  the  duration  of  the  symptoms.  The  mortality  in  young 
infants  is  high.  Yet  patients  will  sometimes  improve  rapidly  when  a 
proper  diet  is  instituted.  The  danger  from  infections  of  different  sorts  is 
great,  and  the  infants  appear  to  have  but  little  resisting  power  to  them. 

The  acute  inanition  from  insufficient  nourishment  generall}'  offers  a 
favorable  prognosis,  it  it  has  not  advanced  too  far;  and  recovery  is  rapid 
when  the  dietetic  defect  is  remedied.  Very  often,  however,  the  patient 
has  developed  through  lack  of  food  an  intolerance  for  it,  and  the  prog- 
nosis is  then  unfavorable.  In  this  connection  must  be  emphasized  the 
danger  of  starvation-treatment  as  the  first  step  in  the  course  of  the  man- 
agement of  cases  of  indigestion  in  infants  much  debilitated.  It  is  the 
proper  treatment  in  acute  cases  with  good  general  health;  but  in  those 
with  but  feeble  strength  it  may  precipitate  a  most  dangerous  state  of 
inanition  if  continued  undul3^ 

Treatment. — The  treatment  of  malnutrition  depends  naturally 
upon  the  cause.  Inasmuch  as  this  is  so  often  dietetic  and  hygienic,  the 
first  effort  must  be  made  to  discover  what  may  be  the  error  in  this 
particular  and  to  correct  it. 

As  regards  the  malnutrition  of  infants,  inanition  occurring  in  those 
breast-fed  requires  a  careful  study  of  the  composition  and  amount  of 
milk  secreted,  as  well  as  the  determining,  in  the  event  that  nothing  is 
wrong  in  this  particular,  whether  the  infant,  perhaps  weakly,  is  actually 
drawing  sufficient  nourishment  from  the  breast.  It  may  be  necessary 
to  pump  or  express  the  milk  and  to  feed  it  from  a  bottle  or  dropper  or  by 
gavage.  In  infants  artificially  fed  who  refuse  their  nourishment,  feeding 
by  gavage  may  be  necessary.  In  young  infants  in  whom  the  state  of  mal- 
nutrition depends  upon  digestive  disorders,  the  securing  of  breast-milk  is 
often  an  essential  for  recovery.  This  may  be  fed  in  small  amounts  at 
frequent  intervals,  or  in  larger  quantities  with  longer  pauses,  depending 
upon  the  attendant  symptoms  and  the  results  obtained.  When  the 
employment  of  substitute-feeding  is  unavoidable,  the  food  may  be  care- 
fully selected  according  to  the  indications  of  the  symptoms.  (See  Chronic 
Gastritis,  p.  723;  Chronic  Intestinal  Indigestion,  p.  763,  etc.)  In  general 
the  high-protein  foods,  such  as  casein-milk  and  buttermilk,  are  most  effica- 
cious. Sometimes  malt-soup  gives  excellent  results;  in  other  cases  whey, 
white  of  egg,  and  the  like,  are  valuable  as  temporary  expedients.  It  is 
necessary  to  make  sure  that  the  food  is  of  sufficient  strength  to  supply  the 
caloric  needs.  In  the  case  of  malnutrition  dependent  upon  excessive 
amount  of  starch,  the  dietetic  remedy  is  obvious.  Inasmuch  as  the 
trouble  is  not  so  much  the  starch  as  the  nearly  or  complete  absence  of 
fat  and  protein  and  possibly  of  salts,  these  ingredients  must  be  supplied 
and  the  starch  withdrawn  or  reduced  in  amount. 

Next  to  the  management  of  the  diet  in  infancy  that  of  the  hygiene  is 
of  the  most  importance.  The  chief  error  here,  both  among  poor  and 
rich,  is  deficient  fresh  air,  the  child  being  confined  by  night  and  often  by 
day  to  close,  poorly  ventilated  rooms.  Whatever  risk  there  may  be  from 
exposure,  that  of  keeping  the  infant  housed  is  certainly  much  greater. 
There  is  naturally  a  middle  course  advisable  in  all  cases  of  much  debili- 
tated infants,  and  enthusiasm  for  open-air  treatment  should  not  lead  to 
exposure  to  chilling,  especially  in  patients  with  a  tendency  to  low  body- 
temperature,  who  bear  this  very  badly.     The  employment  of  hot  water 


MALXUTRITIOX  619 

bottles  and  the  careful  screening  against  cold  wind  will  permit  of  open-air 
treatment  in  many  cases,  while  in  others  the  keeping  of  the  infant  in  a 
well-warmed  room  with  the  windows  open  may  constitute  a  satisfactory 
compromise. 

A  number  of  other  measures  may  be  serviceable,  according  to  the 
needs  of  the  case.  In  atrophic  infants  with  vomiting  or  diarrhea,  who 
are  taking  or  retaining  but  little  nourishment,  frequently  the  most  press- 
ing need  is  that  of  water  in  the  tissues.  In  such  an  event  enteroclysis 
with  normal  sahne  solution  is  often  of  the  greatest  value.  When  it  is  not 
satisfactorily  retained,  hypodermoclysis  may  be  required.  Cardiac  stimu- 
lants should  also  be  used  as  the  occasion  demands.  In  other  cases  of 
malnutrition  gentle  massage,  such  as  the  mother  herself  can  give,  is  of 
service. 

In  the  treatment  of  malnutrition  in  older  children  the  causes  are 
so  manifold  that  only  a  careful  study  of  the  conditions  which  have  ob- 
tained from  infancy  onward  can  guide  to  a  successful  result.  Here,  too, 
the  diet  is  often  at  fault,  although  not  so  predominatingly  as  during 
infancy.  In  all  classes  of  society  the  greatest  ignorance  and  carelessness 
is  often  shown  by  parents  in  these  matters.  The  appetite  for  the  meals 
is  spoiled  by  allowing  cakes,  candies,  and  the  like  between  meal-times. 
The  fancies  of  the  child  are  made  the  guide  rather  than  what  is  best  for  it; 
sometimes  on  the  ground  that  if  denied  the  manifestly  improper  articles 
of  food  it  will  take  nothing.  The  ultimate  result  is,  however,  always  bad. 
The  diet  should  be  simple,  yet  sufficiently  varied  if  food  of  one  nature 
palls,  as  is  often  the  case.  Whether  the  child  shall  be  urged  to  eat 
depends  upon  the  individual.  As  a  rule,  if  voluntarily  going  without  a 
meal,  the  patient  will  often  have  a  better  appetite  for  the  next  and  will 
make  up  the  deficienc}'.  Yet  some  children  seem  to  have  been  born 
with  a  constitutional  lack  of  appetite,  and  in  these  unobtrusive  persuading 
to  eat  is  often  a  necessity.  This  is,  however,  frequently  much  overdone 
by  parents,  and  awakens  in  the  child  a  hysterical  objection  to  the  taking 
of  food  of  any  sort.  (See  "Anorexia  nervosa,"  p.  706.)  When  the  appetite 
is  poor  proper  selection  should  be  made  of  the  sort  of  food  which  will 
nourish  most.  Thus,  for  instance,  I  have  seen  children  satisf}'  themselves 
when  beginning  a  meal  with  a  thin  soup,  and  refuse  the  following  more 
substantial  substances;  and  have  succeeded  in  modifying  this  by  giving 
the  soup  as  a  dessert,  it  making  no  practical  difference  whether  this  article 
was  then  declined  or  not. 

The  whole  course  of  the  child's  daily  life  must  be  supervised  by  the 
physician.  There  is  in  many  instances  far  too  much  confinement  to 
the  house  or  in  school,  and  far  too  much  pushing  in  an  educational  line. 
The  child  spends  the  greater  part  of  both  morning  and  afternoon  in  scliool, 
and  on  retuining  home  has  lessons  in  piano-music,  modelling,  foreign 
languages,  drawing,  and  so  on.  There  is  no  opportunity  given  for  active 
outdoor  amusement,  and  it  is  not  long  until  a  distaste  for  this  arises, 
and  the  patient  has  to  be  driven  from  the  house  to  partake  in  it.  In  other 
children,  on  the  other  hand,  the  fondness  for  outdoor  sports  exists  to 
such  an  extent  that  long  before  evening  the  child  is  in  an  over-tired  state, 
ready  to  cry  on  the  slightest  provocation,  ami  a  night  trouble!  by  in.som- 
nia  ff)llows.  Parents  often  fail  to  remember  that  a  child  never  knows 
enough  to  stop  |)lav  before  becoming  tireil  out.  The  same  niTxous  con- 
dition arises  from  over-excitement  of  any  other  sort,  such  as  going  fre- 
quently to  the  theater,  moving-picture  shows,  children's  parties,  and  the 
like. 


620  THE  DISEASES  OF  CHILDREN 

Enough  has  been  said  to  illustrate  the  great  necessity  of  a  thorough 
study  of  the  child's  daily  life  and  the  proper  regulation  of  this.  Certain 
other  therapeutic  measures  may  be  considered.  Massage  and  gym- 
nastic training  are  useful  for  children  who  take  too  little  exercise,  but 
not  suitable  for  those  who  take  too  much.  Rest,  recumbent,  in  the  mid- 
dle of  the  day,  not  insisting  upon  sleeping  in  the  case  of  those  in  later 
childhood,  is  sometimes  remarkably  efhcacious.  A  cool  morning  spong- 
ing or  affusion  is  often  an  excellent  stimulating  measure  if  the  brisk 
after-rubbing  brings  about  a  good  reaction.  The  bath-room  should  be 
warm  and  the  child  should  stand  in  the  tub  in  a  few  inches  of  warm  water, 
this  being  used  for  cleansing  purposes.  Finally,  the  common  observation 
that  the  children  enjoy  the  best  health  when  out  of  town  during  the  sum- 
mer months,  indicates  that  in  many  instances  life  in  the  country  daring 
the  whole  year  is  what  will  do  most  good. 

The  employment  of  drugs  occupies  a  very  minor  position  in  all 
cases  of  malnutrition  of  any  age.  They  should  be  used  chiefly  symptom- 
atically  as  the  need  arises.  Particular  attention  must  be  paid  to  the 
relief  of  the  chronic  constipation  which  is  so  often  an  attendant.  The 
anemia  which  is  a  frequent  symptom  may  need  a  prolonged  course  of 
iron.  Cod-liver  oil  is  excellent  in  many  instances,  provided  it  does  not 
produce  coating  of  the  tongue  and  loss  of  appetite.  Children  usually 
take  it  readily  if  made  into  an  emulsion  or  given  combined  with  a  syrupy 
extract  of  malt. 


CHAPTER  V 
RHEUMATISM 


Rheumatism  is  often  classified  among  the  infectious  disorders,  and 
certainly  shows  a  close  similarity  at  times  to  infections  of  a  septic  nature. 
For  various  reasons,  however,  it  seems  more  convenient  to  consider  it 
provisionally  among  the  general  and  nutritional  diseases;  at  least  until 
such  time  as  the  invariable  causative  relationship  of  a  specific  germ  may 
be  definitely  proven  beyond  possibility  of  question. 

Etiology.  Predisposing  Causes. — Age  is  important  among  these. 
In  infancy  rheumatism  of  any  form  is  very  rare.  I  have  seen  but  1 
instance  of  articular  involvement  at  this  period,  occurring  in  a  male 
infant  of  8  months,^  and  Miller  writing  in  1899^  found  recorded  under  1 
year  of  age  only  19  cases,  in  addition  to  1  of  his  own,  which  seemed 
properly  to  belong  to  this  class.  Yet  a  few  instances  have  been  reported 
which  appear  to  have  been  congenital  (Abraham).^  It  is  uncommon  in 
early  childhood,  but  after  this  period,  especially  in  some  of  its  varied  forms, 
steadily  increases  in  frequency.  Langmead''  analyzed  the  conditions  exist- 
ing in  2556  school  children  from  33>^  to  14  years  of  age,  and  found  definite 
rheumatism  in  133.  The  individual  predisposition  at  this  time  is,  how- 
ever, not  very  great,  Baginsky^  finding  articular  rheumatism  in  but 
1.4  per  cent,  of  10,375  children  coming  to  the  hospital,  and  Wachenheim^ 
113  instances  in  about  8000  children.  Girls  appear  to  be  attacked 
rather  oftener  than  boys.     In  the  fatal  cases  in  children  there  are  about  3 

1  Arch,  of  Ped.,  1908,  April. 

2  Arch,  of  Ped.,  1899,  Sept. 

3  Med.  Rec,  1896,  L,  547. 
^Lancet,  1911,  II,  1133. 

6  Berl.  klin.  Wochenschr.,  1904,  XLI,  1213. 
«  Arch,  of  Pediat.,  1908,  XXV,  669. 


RHEUMATISM  621 

females  to  2  males  (Poynton,  Agassiz  and  Taylor).^  Inheritance  is  a 
factor  of  importance,  certain  families  seeming  especially'  predisposed, 
either  the  parents  or  other  children  having  suffered  from  the  disease. 
Kephallinos-  discovered  evidences  of  inheritance  in  50.7  per  cent,  of 
69  cases.  Defective  hj'giene,  especialh'  exposure  to  cold  and  dampne-ss 
or  to  sudden  alterations  of  temperature,  is  perhaps  the  most  influential 
predisposing  factor.  For  this  reason  rheumatism  is  more  prevalent  in 
the  cooler  and  damper  season  of  the  year. ;  and  this,  too,  explains  the  fact 
that  some  years  and  some  countries  produce  many  more  cases  of  rheuma- 
tism than  others. 

Exciting  Cause. — The  direct  cause  of  the  disease  is  unknown.  Ex- 
cessive acidity  of  the  blood,  dependent  especially  upon  lactic  acid,  has 
been  claimed  to  be  influential,  but  there  appears  to  be  no  proof  of  this. 
Microorganisms  have  been  discovered  in  the  blood,  heart  and  joints 
by  various  observers,  probably  first  by  Popoff  in  1887.^  One  of  the  most 
important  contributions  is  that  of  Pojmton  and  Paine,"*  who  found  cocci 
(streptococcus  rheumaticus)  in  fatal  cases  of  rheumatism,  present  in 
the  joints,  blood,  heart  and  tonsils.  They  considered  these  the  cause, 
and  that  they  probably  entered  by  way  of  the  tonsils,  since  rheumatic 
individuals  appear  especially  predisposed  to  tonsillar  inflarnmation, 
and  the  characteristic  rheumatic  symptoms  are  in  many  cases  immedi- 
ately preceded  b}'  an  acute  angina.  Later  studies  by  them'  confirmed 
their  past  experience,  and  Coombs,  Miller  and  Kettle"  and  others  pro- 
duced arthritis  and  carditis  in  rabbits  inoculated  with  streptococci 
obtained  from  rheumatic  individuals.  Whether  or  not  any  variety 
of  microorganism  can  be  considered  the  specific  cause  remains  to  be 
proven.  Certainly,  if  so,  there  must  be  some  powerful  constitutional 
susceptibihty  present  as  well.  Family  outbreaks,  it  is  true,  point  de- 
cidedly to  an  infectious  nature  of  the  disease  (Allaria)^  yet  but  few  such 
instances  have  been  reported,  and  it  is  difficult  to  understand  the  asso- 
ciation of  infection  with  the  sudden  development  of  such  nervous  manifes- 
tations of  rheumatism  as  seen,  for  instance,  in  many  cases  of  chorea. 

Pathological  Anatomy. — There  are  no  characteristic  articular 
lesions  in  acute  cases  beyond  hyperemia  with  turbidity  of  the  fluid, 
and  slight  infiltration  of  the  neighboring  connective  tissue.  As  a  rule  no 
bacteria  are  found,  in  the  experience  of  most  observers.  Purulent  in- 
flammation occurs  only  as  a  complication.  In  the  chronic  cases  there  is 
decided  effusion  into  the  joint,  with  thickening  of  the  cap.sule  and  liga- 
ments, erosion  of  the  cartilage,  and  finally  involvement  of  the  bones 
resulting  in  ankylosis.  Fibrous  nodules  arc  sometimes  present  beneath 
the  skin  in  various  regions  in  children.  These  consist  of  connective 
tissue  of  an  inflanuuatory  nature,  fibrin,  and  cells.  The  lesions  of  rheu- 
matic endocarditis  and  pericarditis  will  be  considered  in  the  chapter  upon 
Disea.ses  of  the  Heart. 

Symptoms. — For  the  correct  understanding  of  the  manifestations 
of  rheumatism  in  children,  the  idea  nuist  be  banished  that  the  affection 

'  The  PrartitioiuT,  1914,  XCIII,  445. 

-•  Wien.  klin.  Woch.,  UHM),  XIX,  rAVi. 

3  Medit.  Prol):ivl()iia  K.  Moskowii  Sboneskie,  1S87,  401.  Hi'f.,  Dunn,  .Journ. 
Amor.  Med.  Assoc,  1907,  LXVIII,  493. 

'  Lancet,  1900,  II,  StiO. 

••>  Lancet,  1910,  I.  .')24. 

"Lancet,   1912,  II.   1209. 

^  Revistii  crit.  di  mod.  din.,  1901,  Xov.  23.  Ket.,  Hrif.  Med.  Journ.,  1902, 
Jan.  11.     Current  Lit.,  '). 


622 


THE  DISEASES  OF  CHILDREN 


must  show  itself  in  the  same  manner  as  in  adults.  The  symptoms  of 
rheumatism  in  early  life  are  manifold.  While  an  acute  arthritis  is 
the  type,  yet  there  may  be  no  involvement  of  the  joints  at  all,  or  this 
may  occur  secondarily.  Particular  notice  must  be  taken  of  the  vague, 
trifling  pains  in  the  joints  or  muscles,  which  are  ignored  by  parents,  but 
which  can  readily  be  followed  by  affections  of  the  heart  or  by  chorea. 
Cardiac  involvement  is  especially  common  in  children  and  is  often  the 

first  manifestation.  Tonsillar  inflammation 
or  torticollis  may  be  quickly  followed  by 
arthritis,  or,  even  without  this,  Ijy  peri- 
carditis or  endocarditis.  Chorea  may 
succeed  articular  inflammation  or  msiy 
precede  it,  or  be  followed  by  cardiac  in- 
flammation without  any  arthritis.  Sub- 
cutaneous fibrous  nodules  may  be  the  first 
symptom  or  may  occur  subsequently  to 
articular  disease.  Indeed,  any  one  of 
these  conditions  may  be  the  first  to  appear, 
but  is  liable  soon  to  be  followed  by  others. 
Although,  therefore,  articular  rheumatism 
may  be  considered  the  type,  the  other 
conditions  are  rather  to  be  considered 
forms  of  rheumatic  manifestations  than 
complications. 

Acute  Articular  Rheumatism. — Occa- 
sionally preceded  by  malaise,  or  sometimes 
by  sore  throat  for  several  days,  the  attack 
generally  begins  acutely  with  fever,  loss  of 
appetite,  and  swelling,  pain,  and  redness  in 
one  or  several  joints.  The  intensity  of 
these  symptoms  varies  greatly.  In  early 
childhood  they  are  less  marked  than  later, 
and  at  any  time  in  early  life  the  articular 
symptoms  are  usually  not  so  decided  as  in 
adults,  the  redness,  swelling  and  pain  are 
less  evident,  sweating  absent  or  slight, 
and  the  fever  is  less,  reaching  103°  to  104°F. 
(39.4°  to  40°C.)  at  the  onset  but  soon  fall- 
ing to  about  101°F.  (38.3°C.)  (Fig.  220). 
Generally  the  joints  of  the  lower  extremities 
are  first  affected,  the  ankle  or  knee  oh  one 
side  being  much  oftenest  attacked,  with 
the  hip  usually  next  in  order  of  frequency. 
The  disease  may  remain  limited  to  a  single 
joint,  but  as  a  rule  the  corresponding  joints 
of  the  other  side  are  soon  involved  also,  and  perhaps  the  wrists,  elbows 
and  shoulders  as  well;  or  not  infrequently  the  joints  of  the  upper  ex- 
tremity may  be  attacked  alone  or  primarily.  Sometimes  the  disease 
appears  in  the  cervical  vertebrae,  less  often  in  the  fingers  and  toes  or 
other  joints.  Quite  often  one  joint  improves  as  another  becomes 
affected,  but  it  is  not  uncommon  for  the  inflammation  to  reappear  in  the 
first  joint  as  the  course  of  the  disease  progresses.  As  a  rule  not  many 
joints  are  involved. 

In  the  mild  attacks,  such  as  are  seen  especially  in  early  life,  the 


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Rheumatism. 
Alice  W.,  aged  6  years.  After 
becoming  overheated  by  skating, 
developed  headache,  fever,  and 
pain  in  the  knees,  ankles  and  feet. 
On  entrance  to  the  Children's 
Ward  of  the  University  Hospital, 
Philadelphia,  May  16,  exhibited 
pain,  redness  and  swelling  of  both 
knees,  tongue  coated.  No  cardiac 
murmur  present.  Leucocytes 
30,200;  May  22,  swelling  and  pain 
nearly  gone.  A  faint  systolic 
murmur  audible. 


RHEUMATISM 


623 


patient  may  not  feel  ill,  the  fever  is  insignificant,  and  the  child  is  not 
confined  to  bed  unless  the  lower  extremities  are  affected.  Often  there  is 
only  sufficient  pain  to  produce  lameness  without  actual  inability  to  walk. 
The  discomfort  is  frequently  so  insignificant  that  it  is  given  by  the  parents 
the  common  title  of  "growing  pains." 

The  well-marked  typical  attacks  of  the  adult  type  are  not  often  seen 
until  toward  the  end  of  later  childhood.  Here  the  expression  of  the  face 
is  one  of  pain  and  the  tenderness  of  the  inflamed  joints  is  exquisite,  any 
change  of  position  causing  severe  suffering.  The  urine  is  high-colored 
and  diminished  in  amount  and  usually  acid,  and  there  is  abundant  acid, 
sour-smelling  perspiration.  The  blood  in  these  cases  exhibits  a  moderate 
leucocytosis,  and  anemia  develops  if  the  case  is  long  continued      There 


1-H;.     221. (HifOXIC  ArTUTLAU    KlIKlMATrSM. 

Showing  ciilaiKement  of  the  elbows,  hands  and  knees.     Same  case  as  in  Fig.  222. 

is  coating  of  the  tongue  and  loss  of  appetite.  The  temperature  remains 
elevated,  sometimes  with  exacerbations  as  fresh  joints  are  attacked. 
Delirium  and  other  cerebral  disturbances  are  rare  at  any  period  of  child- 
hood. 

The  duration  of  acute  articular  rheumatism  is  varial)le.  In  average 
cases  it  is  from  1  to  2  weeks,  but  the  remarkable  tendency  to  relapse  may 
lengthen  the  course  very  greatly.  Some  cases  pass  into  the  chronic 
form,  but  this  is  much  less  common  than  in  adults. 

Chronic  Articular  Rheumatism. — Under  this  heading  may  lie  included 
disorders  described  as  rheumatoid  arthritis,  arthritis  (leformans,  and  by 
other  titles.  The  relationship  of  these  to  each  other  and  to  acute  articular 
rheumatism  is  still  far  from  determined.  Provisionally  they  may  all  be 
considered  as  manifestations  of  chronic  rheumatism,  inasmuch  as  it 
seems  imi)ossil)le  to  draw  any  sharp  line  of  demarcation  between  them. 
Chronic  rheumatism  is,  fortunately,  uncommon  in  early  life.  Ibrahim.' 
1  Zeit.  f.  orthop.  Chirurg.,  lOU.  XXXIV.  2111 


624 


THE  DISEASES  OF  CHILDREN 


however,  reported  upon  273  collected  cases  including  certain  of  his  own. 
Shghtly  more  than  i  9  were  less  than  6  years  of  age.  I  have  seen  a  very 
considerable  number  of  instances.  It  may  follow  an  acute  attack  with- 
out any  cessation  of  symptoms,  or  maj^  be  the  final  result  of  a  series  of 
relapses  or  recrudescences.  A  second  class  of  cases  has  certain  points 
of  difference,  yet  cannot  be  clearly  distinguished.  In  this  the  course  is 
subacute  or  chronic  and  progressive  from  the  beginning  (Rheumatoid 
arthritis)  (Fig.  221).  Either  form  may  begin  in  the  larger  joints  usually 
attacked  in  acute  articular  rheumatism,  Init  there  is  a  tendency  to  pri- 
mary localization  in  the  hips,  small  joints  of  the  fingers,  jaws,  or  the 


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Fig.  222. — Chronic  Articular  Rheumatism. 
Ignatio  C,  aged  7  years.  At  20  months  developed  painful  swelling  of  knees  and 
fingers.  In  bed  3  or  4  months.  Then  entirely  well  until  Dec,  1912,  when  gradually 
all  joints  of  lower  limbs,  the  hands  and  the  -elbows  became  swollen  and  painful,  neck 
stiff.  Been  confined  to  bed  ever  since.  Admitted  to  the  Children's  Hospital  of  Phila- 
delphia, Oct.  2.5,  191.3.  Poorly  nourished;  very  bad  teeth;  >vrists,  elbows,  ankles,  fingers 
and  toes  swollen  but  not  tender;  neck  stiff;  fixation  at  hips;  knees  swollen  and  tender; 
spleen  not  enlarged.  Leucocytes  12,000.  Von  Pirquet  reaction  negative.  Teeth 
treated  by  dentist.     Removed  unimproved. 


neck.  This  is  especially  true  of  the  second  class  of  cases.  The  disease 
spreads  from  joint  to  joint  without  disappearing  in  those  first  affected, 
until  the  majority  of  the  articulations  are  involved.  There  is  increasing 
debihty  and  anemia,  and  a  tendency  to  cold,  clammy  sweating.  Endo- 
carditis may  occur  in  either  group,  but  less  often  in  the  second.  Fever 
is  usually  moderate  (Fig.  222)  or  absent.  Periods  of  improvement  occur 
but  u-sually  without  complete  disappearance  of  symptoms.  At  these 
times  pain  on  movement  may  be  moderate,  but  it  becomes  severe  during 
the  exacerbations.  The  joints  become  swollen  and  distorted  and  grate 
when  moved;  the  skin  over  them  shining  and  the  neighboring  muscles 
atrophied.     There  is  involvement  of  the  cartilages  and  bony  structures 


RHEUMATISM  625 

and  the  periarticular  tissues,  and  the  final  production  of  great  deformity 
of  the  joints  {Arthritis  deformans)  and  of  ankylosis.  A  special  form  of 
chronic  arthritis  has  been  described  by  StilP  which  is  possibly  rheumatic, 
possibl}'  tuberculous,  or  dependent  upon  some  chronic  infection.  It  is 
characterized  by  progressive  involvement  of  the  joints,  which  become 
enlarged  and  stiff  but  not  very  painful,  but  which  do  not  undergo  de- 
structive processes.  There  is  more  or  less  fever  and  always  enlargement 
of  the  spleen  and  of  the  l3miph  nodes. 

There  is  reason  to  believe  that  all  the  forms  of  chronic  articular 
rheumatism  depend  upon  a  chronic  infection  arising  from  the  tonsils, 
sinuses,  joints,  or  the  roots  of  the  teeth.  It  has  also  been  claimed  that 
it  may  be  dietetic  in  origin  (Pemberton).- 

Cardiac  Rheumatism. — As  already  stated,  this  is  sometimes  the  first 
manifestation  of  the  disease,  being  evidenced  by  fever  and  vague  general 
symptoms,  the  cause  of  which  is  unknown  until  a  cardiac  murmur  be- 
comes audible,  and  perhaps  other  characteristic  symptoms  developing 
later  prove  that  the  affection  is  of  a  rheumatic  nature.  Oftener,  how- 
ever, cardiac  symptoms  are  secondary  to  chorea  or  arthritis.  Involve- 
ment of  the  heart  is  especially  liable  to  occur  in  childhood,  and  although 
more  frequent  during  the  severe  attacks  of  articular  rheumatism,  it  is 
common  even  in  the  mildest.  In  fact,  the  articular  inflammation  may 
have  been  so  slight  as  to  have  been  overlooked.  Endocarditis  is  the 
most  frequent  lesion.  A  certain  degree  of  this  is  present  in  probably  the 
majority  of  cases  of  articular  rheumatism,  as  shown  b}^  the  acceleration 
of  the  pulse-rate,  which  is  so  often  out  of  proportion  to  the  elevation  of 
temperature.  It  appears  usually  about  the  end  of  the  1st  week  of  the 
articular  attack,  or  earlier.  Coombs^  found  cardiac  lesions  in  60  per  cent, 
of  75  children  with  rheumatic  disease,  and  Kephallinos^  in  about  70  per 
cent,  of  129  cases.  A  valvular  lesion,  generally  mitral,  persists  in  probably 
y2  01"  more  of  the  cases  of  articular  rheumatism  in  children,  developing  in 
later  attacks  if  not  in  the  first.  Pericarditis,  although  less  common,  is 
very  characteristic  of  rheumatism  in  children,  occurring  in  from  10  per 
cent,  to  20  per  cent,  of  the  cases  of  articular  rheumatism.  It  is  seen  much 
oftener  than  in  adult  life.  Nearly  always  accompanied  by  endocarditis, 
it  has  generally  a  sudden,  acute  onset,  followed  by  effusion,  and  finally 
often  bv  more  or  less  obliteration  of  the  pericardial  sac.  (See  Diseases 
of  the  Heart,  Vol.  II,  pp.  113,  140,  141.) 

Chorea. — This  is  a  frequent  mainfestation  of  rheumatism,  although 
not  all  instances  of  chorea  can  be  called  rheumatic.  In  226  cases  of  chorea 
reported  by  Still^  at  least  126  (55.7  per  cent.)  e.vhibited  rheumatism. 
The  question  of  the  relationship  of  the  two  conditions  is  furthei  discussed 
in  the  chapter  upon  (/horea.  It  may  ha  the  primary  disorder  and  may 
be  followed  by  arthritis,  but  oftener,  if  the  combination  exists,  the  latter 
is  the  first  to  develop.  As  the  symptoms  of  chorea  appear,  those 
of  articular  inflammation  may  suddenly  cease.  Very  frequently  it  occurs 
without  any  articular  involvement  whatever,  and  is  then  often  followed 
by  endocartlitis.     All  three  conditions  may  i)e  present  at  the  same  time. 

Subcutaneous  Fibrous  Nodules  (Fig.  223). — ^Although  first  described 
by  Aleynef'  this  alfection  has  Ix'en  most  frequently  recorded  by  English 

1  Med.  Chir.  Transjic,  1S07,  I-XXX.  47. 

2  .\mor.  Jour.  iMed.  Sci.,  IDIl,  CXLVIl,  4JH. 

3  BrLstol  Med.-Chir.  Journ.,  l'.H)7,  XXV,  l',»;5. 
*  Loc.  cit. 

5  Pniftitionor,  1001,  LXVI,  r^.\. 
8  Lyon  iiR-d.,  1875,  XX,  4'J.5. 
40 


626  THE  DISEASES  OF  CHILDREN 

physicians.  Barlow  and  Warner^  in  1881  reported  upon  37  cases  in 
children.  In  the  United  States  it  certainly  appears  to  be  uncommon,  and 
the  same  would  appear  to  be  true  for  Germany  (Berkowitz).-  I  have 
encountered  it  in  but  few  instances.  It  appears  to  be  more  frequent 
in  children  than  in  adults.  The  nodules  v?.ry  in  size  from  that  of  a  pin- 
head  to  that  of  a  small  nut,  are  not  reddened  or  tender,  and  are  found 
oftenest  upon  the  back  of  the  head,  about  the  joints,  especially  the  elbows, 
knees  and  ankles,  along;  the  tendons  and  the  vertebrae  and  upon  the  pinna 
of  the  ear.  They  are  distributed  somewhat  symmetrically,  vary  in  number 
from  very  few  to  50  or  more  and  generally  develop  after  the  articular 
inflammation  appears,  although  I  have  seen  them  abundant  before  this. 
They  usually  take  some  weeks  to  disappear,  and  may  exceptionally  last 
manv  months. 


Fig.  223. — Subcutaneous  Fibrous  Nodules. 
Boy  of  4j^  years.     Chorea,  chronic  endocarditis,  nodules  about  the  wrists  and  ankles. 
(Berkowitz,  Arch.  f.  Kinderhk.,  1912,  LIX,  6.) 

Cutaneous  Manifestations. — Rheumatic  subjects  are  prone  to  attacks 
of  erythema  of  various  forms,  with  which  articular  inflammation  is  often 
associated.  Purpura  too,  is  sometimes  combined  with  rheumatic  arthri- 
tis, with  or  without  erythema.  It  is  far  from  certain,  however,  that  the 
majority  of  cases  of  arthritis  with  purpura  have  any  connection  with 
rheumatism.     (See  Purpura,  Vol.  II,  p.  477.) 

Tonsillitis. — As  already  stated,  inflammation  of  the  tonsils  or  pharynx 
may  be  promptly  followed  by  articular  inflammation  or,  even  without 
this,  by  cardiac  disease.  There  seems  to  be  a  special  tendency  to  ton- 
sillitis in  evidently  rheumatic  subjects. 

Muscular  Rheumatism.  Rheumatic  Myalgia. — The  question  whether 
this  condition  is  actually  rheumatic  has  been  much  disputed.  There 
appears  to  be  no  doubt,  however,  that  at  least  some  of  the  cases  of  myal- 
gia are  evidences  of  rheumatic  disease.  This  is  true,  in  children  especially, 
of;  the  acute  torticollis  which  is  characterized  by  sudden  onset,  great 
soreness  and  stiffness  of  the  neck  chiefly  in  the  sternocleidomastoid 
muscles,  rapid  disappearance,  and  association  with  tonsillitis  or  other 
rheumatic  manifestations.  It  is  to  be  distinguished  from  rheumatism 
of  the  cervical  vertebral  articulations.  I  have  seen  arthritis  and  cardiac 
involvement  quickly  follow  torticollis.     (See  Torticollis,  Vol.  II,  p.  411.) 

Another  evidence  of  muscular  rheumatism  common  in  children  are 
the  so-called  "growing  pains"  located  in  the  extremities,  to  which  little 
attention  is  paid  as  a  rule,  but  which  may  be  followed  by  cardiac  involve- 

1  Transac.  of  the  Internal.  Med.  Cong.,  1881,  IV,  116. 

2  Arch.  f.  Kinderh.,  1912,  LIX,  2. 


RHEUMATISM  627 

ment.  Most  frequently.,  however,  these  growing  pains  are  probably- 
located  in  the  joints.  Lumbago,  pleurodynia,  and  other  localized  myal- 
gias are  less  common  in  early  life. 

Complications. — Other  conditions  less  common  than  those  described 
may  complicate  rheumatism,  some  of  them  exceptionally.  Among  these 
are  vomiting,  peritonitis,  pleuritis,  pneumonia,  nephritis,  bronchitis, 
iritis,  trigeminal  neuralgia,  sciatica,  venous  thrombosis,  epistaxis  and 
mastitis. 

Recurrence  and  Relapse. — One  attack  of  rheumatism  is  extremely 
liable  to  be  followed  by  later  ones,  especially  in  childhood.  There  is 
rather  the  reverse  of  a  protective  influence.  The  severity  of  the.  recur- 
rences is  in  no  way  dependent  upon  that  of  the  primary  attack. 

The  tendency  for  the  disease  to  relapse  is  very  great.  These  relapses 
may  take  place  in  spite  of  the  greatest  care  and  entirely  without  discover- 
able cause,  or  they  may  be  brought  on  by  slight  exposure,  such  as  leaving 
the  bed;  a  week  or  so  after  convalescence  seems  established.  The  disease 
may  appear  in  the  joints  originally  affected  or  in  others.  Repeated 
relapses  may  occur  one  after  the  other,  the  severity  being  independent 
of  that  of  the  first  attack. 

Prognosis.^ — The  prognosis  in  children  is  better  than  in  adults  so 
far  as  recovery  from  the  individual  attack  is  concerned.  The  course  of 
arthritis  is  shorter  and  the  symptoms  milder.  Endocarditis,  if  slight,  is 
frequently  recovered  from;  if  more  severe,  valvular  insufficiencj^  remains 
but  compensation  is  much  more  easily  acquired  in  children  than  in  later 
life.  (See  Endocarditis,  Vol.  II,  p.  41.)  The  prognosis  of  rheumatism  on 
the  whole,  however,  is  more  serious  in  early  life,  on  account  of  the  greater 
tendency  to  recurrence  of  arthritis  and  chorea,  and  the  greater  probability 
that  endocarditis  will  develop  in  later  attacks,  if  not  in  the  primary  one; 
or  that  if  already  present,  it  will  become  worse  on  each  reappearance  of 
rheumatic  disease.  This  great  disposition  to  the  development  of  cardiac 
involvement  in  early  life  makes  the  prognosis  of  rheumatism  in  children 
always  doubtful.  Rheumatic  pericarditis  in  children  is  exceedingly 
liable  to  lead  to  loss  of  cardiac  compensation.  The  studies  of  Poynton, 
Agassiz  and  Taylor^  upon  350  fatal  cases  of  rheumatism  indicated  that 
the  disease  was  at  its  worst  from  the  6th  to  the  12th  year,  and  the  large 
majority  of  deaths  occurred  before  the  age  of  20  years.  The  cause  of 
death  in  early  life  was  nearly  always  cardiac  involvement. 

The  prognosis  of  chronic  articular  rheumatism  is  very  grave.  Though 
the  course  of  the  disease  is  always  slow,  it  is  more  rapid  than  in  adults. 
Some  of  the  milder  cases  may  recover,  but  this  is  exceptional.  Death 
finally  occurs  from  exhaustion  or  some  intercurrent  disease,  especially 
tuberculosis. 

Diagnosis. — ^Diagnosis  in  early  life  is  not  always  easy  on  account  of 
the  different  guises  under  which  the  disease  may  appear.  The  discovery 
of  a  slight  valvular  lesion  of  the  heart  should  always  awaken  the  sus- 
picion of  rheumatism,  and  an  investigation  should  be  made  into  the  pre- 
vious existence  of  slight  pain  in  the  joints,  growing  pains,  torticollis, 
repeated  sore  throat,  chorea,  and  otiier  rheumatic  manifestations.  So, 
also,  the  development  of  chorea  should  lead  to  a  careful  study  of  the 
personal  and  the  the  family  history  with  regard  to  the  previous  occurrence 
of  rheumatism,  and  to  a  search  for  the  presence  of  endocarditis  or  other 
rheumatic  symptoms. 

An  attack  of  acute  articular  rheumatism  is  generally  easily  recognized, 

^  Loc.  cit. 


628  THE  DISEASES  OF  CHILDREN 

its  characteristic  symptoms  being  sudden  development  of  some  degree  of 
pain,  swelling,  tenderness,  and  redness  in  one  or,  generally,  more  joints. 
A  number  of  other  conditions  may,  however,  be  confounded  with  it  and 
'must  be  eliminated.  Osteomyelitis  is  among  these.  It  is  less  often  multi- 
ple in  its  localization,  exhibits  more  severe  constitutional  symptoms, 
and  involves  the  shafts  and  epiphyses  rather  than  the  joint  itself.  Sec- 
ondary arthritis  after  acute  infectious  diseases,  such  as  scarlatina,  is 
usually  monarticular,  sometimes  polyarticular,  and  is  recognized  by  the 
previous  history  of  the  case.  Gonorrheal  arthritis,  although  usually 
monarticular,  is  more  often  multiple  in  early  life  than  later.  It  is, 
however,  nearly  always  combined  with  vulvovaginitis  or  ophthalmia. 
The  syphilitic  arthritis  sometimes  occurring  as  a  later  manifestation  of 
syphilis  is  localized  in  both  knee-joints,  runs  a  very  chronic  course,  and 
is  generally  associated  with  keratitis  and  other  late  syphilitic  symptoms. 
Septic  arthritis  is  polyarticular,  purulent  in  character,  and  is  always  accom- 
panied by  other  symptoms  of  sepsis.  In  infancy  scorbutus  and  syphilitic 
epiphysitis  are  sometimes  wrongly  called  rheumatism;  but  rheumatism 
is  so  rare  at  this  period  that  it  is  proper  to  assume  its  absence  unless  its 
symptoms  are  unquestionable.  Nearly  all  the  cases  of  pain  in  the  legs 
in  infants,  with  disability  and  without  fever,  are  due  to  scurvy.  (See 
Scurvy,  p.  602.)  Multiple  neuritis  and  sciatica  may  at  first  suggest 
rheumatism  but  exhibit  no  articular  involvement;  and  the  fever  and  pain 
on  being  moved  often  seen  in  poliomyelitis  may  cause  confusion,  but  is 
distinguished  by  the  absence  of  articular  effusion.  Tuberculous  coxitis 
may  also  at  times  occasion  difficulty.  Careful  examination  will  soon  re- 
veal the  true  condition.  Retropharyngeal  abscess  may  in  some  instances 
simulate  torticollis.    The  course  of  the  case  soon  renders  the  diagnosis  clear. 

Treatment.  Prophylaxis. — This  is  by  all  odds  the  most  important, 
since  little  can  be  done  to  influence  a  cardiac  rheumatism  when  present, 
and  it  is  the  cardiac  disease  upon  which  the  gravity  of  the  prognosis 
depends  in  most  cases.  Children  with  a  decided  family  history  of  rheuma- 
tism or  who  have  suffered  from  previous  attacks  should  be  scrupulously 
guarded  against  exposure  to  cold  and  damp,  including  wetting  of  the  feet; 
dressed  warmly  in  woolen  underclothing,  yet  not  so  warmly  that  free 
perspiration  is  produced;  enjoy  an  abundance  of  fresh  air  on  suitable 
days,  and  live  in  dry,  healthful  dwellings.  At  the  same  time  care  must  be 
taken  against  making  the  child  susceptible  by  too  great  precautions.  The 
effort  should  be  made  to  improve  the  general  tone  and  to  increase  the 
resisting  power  to  influences  which  might  prove  harmful.  A  system  of 
hardening  should  be  cautiously  instituted,  through  cool,  morning  spong- 
ing followed  by  vigorous  rubbing,  systematic  gymnastic  exercises  and 
massage,  the  fullest  use  of  these  measures  being  approached  by  degrees. 
In  specially  susceptible  subjects  change  of  residence  in  winter  to  a  warm, 
dry  climate  is  most  advisable. 

Whether  diet  has  any  influence  in  preventing  the  disease  is  disputed. 
The  giving  of  nitrogenous  food  and  the  restriction  of  carbohydrates  has 
been  recommended,  but  the  actual  value  of  these  is  questionable. 

For  the  prevention  of  cardiac  involvement  the  cases  of  even  slight 
articular  rheumatism  should  be  kept  quiet  in  a  warm  room,  and,  if  there 
is  the  slightest  fever,  in  bed.     This  is  all  that  can  be  done. 

Treatment  of  the  Attack. — In  cases  of  acute  articular  rheumatism  the 
diet  during  the  acute  febrile  stage  should  consist  of  milk  or  broths. 
Later  a  simple,  digestible  regimen  may  be  prescribed.  The  patient  should 
be  at  rest  in  bed  in  an  equably  heated  but  well-ventilated  room,  and 


RHEUMATISM  629 

the  slightest  chilHng  should  be  avoided  since  a  relapse  of  the  disease 
may  readily  follow.  The  clothing  should  consequently  be  preferably  of 
flannel,  made  easily  removable  to  facilitate  changing  when  wet  by  the 
sweating.  For  local  treatment  the  affected  joints  may  be  wrapped  in 
cotton  or  with  warm,  moist,  applications  for  the  relief  of  pain;  all  motion 
avoided;  and  the  bed-clothes  prevented  from  pressure  on  tender  regions. 
The  treatment  of  developing  endocarditis  will  be  considered  in  the  section 
upon  Tendocarditis,  Vol.  II,  p.  141.  For  the  direct  medicinal  treatment  of 
the  attack  salicylic  acid  has  been  considered  a  specific.  Whether  or  not  it 
may  be  justly  deemed  so  is  a  matter  of  much  dispute.  There  is  no  doubt 
at  least  that  the  salic3dates  control  both  pain  and  fever.  To  be  of  value, 
sufficiently  large  doses  should  be  given,  5  to  8  grains  (0.32  to  0.52)  of 
the  salicylate  of  soda  being  administered  every  3  hours  to  a  child  8  to  10 
years  of  age.  Very  much  larger  initial  doses  are  recommended  by  some 
clinicians.  The  dose  mentioned  can  be  rapidly  increased  in  size  if 
necessary,  and  if  the  stomach  tolerates  it,  until  moderate  tinnitus  and  deaf- 
ness are  produced.  The  addition  of  an  aromatic,  such  as  ginger,  often 
aids  in  the  tolerance  of  the  drug.  Salicin,  oil  of  wintergreen,  aspirin, 
salol,  and  other  salicjdic  acid  derivatives,  may  be  given  in  place  of  the 
salicylate;  or,  if  the  digestion  will  not  bear  any  internal  administration,  the 
oil  of  wintergreen  (salicylate  of  methyl)  may  be  used  freely  by  inunction 
in  the  armpits  and  similar  suitable  regions.  The  constitutional  effect 
may  be  produced  in  this  way.  When  the  pain  and  fever  are  decidedly 
lessened  the  dosage  may  be  reduced,  but  the  treatment  should  not  be 
abandoned  entirely  for  some  time  after  convalescence  seems  established. 
Where  the  salicylates  fail  to  relieve  pain,  antipyrine  or  phenacetin  may  be 
employed,  alone  or  in  combination  with  these.  For  the  pain  in  severe 
cases  opiates  may  be  necessary.  I  have  never  witnessed  any  of  the  de- 
pressing effects  from  salicylates  which  have  sometimes  been  reported. 
The  alkaline  treatment,  as  with  bicarbonate  of  soda  or  citrate  of  potash, 
has  been  much  esteemed.  It  may  be  combined  with  the  salicylates  and 
should  be  given  in  sufficient  dose  to  render  the  urine  alkaline. 

Experiments  with  serum  and  vaccine  treatment  have  been  made,  but 
the  results  which  have  been  reported  as  encouraging,  demand  further 
corroborative  experience. 

During  convalescence  from  acute  articular  rheumatism  tonic  remedies 
may  be  required,  such  as  arsenic,  iron,  or  cod-liver  oil.  The  treatment  of 
acute  manifestations  of  other  forms  of  rheumatism  will  be  considered  in 
the  different  chapters  discussing  these  subjects. 

In  the  treatment  of  subacute  and  chronic  rheumatism  the  effort  must 
be  made  to  (hscover  the  cause.  In  this  direction  the  condition  of  the 
tonsils  and  mouth  should  be  carefully  examined  and  appropriate  measures 
taken  if  needed.  Autogenous  vaccines  have  been  tried  with  some  reputed 
success.  Apart  from  these  methods  the  persistent  administration  of 
iodide  of  potassium  has  much  in  its  favor.  In  other  cases  arsenic  or  cod- 
liver  oil  is  of  benefit.  Thyroid  extract  has  occasionally  given  good  results. 
Always  the  effort  to  improve  the  general  health  nuist  be  mndv  and  to 
procure  the  most  favoi'abl(>  hygienic  conditions.  JMassnge  and  passive 
movement  oil  the  joints  are  veiy  important,  except  during  exacerbations 
when  rest  is  reciuircd.  Local  applications  of  ichthyol  ointment  or  prepa- 
rations of  iodine  or  mercury  may  be  employed.  Benefit  has  followed  tiie 
production  of  passive  congestion  by  the  Bier  method,  as  well  as  by 
baking  in  a  suitable  apparatus.  Treatment  at  some  one  of  the  t hernial 
springs  is  of  decided  help  and  should  always  be  employed  when  possible. 


630  THE  DISEASES  OF  CHILDREN 

CHAPTER  VI 
THE  DIATHESES 

The  views  of  many  years  ago  concerning  the  existence  of  various 
diatheses  passed  to  a  large  extent  into  the  class  of  forgotten  things, 
under  the  increasing  trend  of  the  attributing  of  nearly  every  disordered 
state  to  the  influence  of  some  infection.  In  recent  years  it  has  become 
evident  that  neither  infection  nor  any  other  active  cause  is  sufficient  by 
itself  to  account  for  the  development  of  certain  disorders  in  certain  persons; 
and  that  diatheses  do,  in  fact,  exist.  By  this  term  is  meant  a  constitu- 
tional tendency  to  the  development  of  certain  sorts  of  diseases  varying 
with  the  individual;  a  tendency  which  makes  the  same  acting  cause  vary  in 
the  character  of  the  symptoms  produced.'  It  is  to  be  noted,  however, 
that  in  the  strict  sense  a  diathesis  is  not  a  disease,  but  a  constitutional 
peculiarity  which  acts  as  a  predisposition. 

Various  diatheses  have  been  described,  the  boundary-lines  between 
them  being  not  sharply  marked,  and  the  list  of  symptoms  attributed  to 
their  influence  varying  with  different  writers.  Among  them  may  be 
mentioned  the  spasmophiUc,  lymphatic,  neuropathic  and  exudative. 
It  is  further  to  be  observed  that  there  is  frequently  a  combination  of 
two  diatheses,  the  evidences  of  both  appearing  in  the  same  individual. 
The  symptoms  of  the  lymphatic  diathesis  are  to  a  large  extent  by  many 
attributed  to  the  exudative  diathesis,  and  it  is  certain  that  there  exists  in 
any  event  a  close  relationship  between  them.  Whether  they  should,  in 
fact,  be  classed  as  one  is  not  yet  possible  of  determination.  Spasmo- 
philia is  by  many  considered  as  one  form  of  the  neuropathic  diathesis, 
and  its  occurrence  in  combination  with  the  exudative  diathesis  is  very 
common;  while  in  other  cases  lymphatic  disturbances  occurring  in  nerv- 
ous subjects  give  rise  to  the  title  "neurolymphatic  diathesis."  All  this 
renders  the  subject  confusing  and  the  divisions  arbitrary  and  conflicting. 

The  spasmophilic  and  neuropathic  diatheses  are  described  elsewhere 
(see  Vol.  II,  pp.  249  and  269)  in  connection  with  Diseases  of  the  Nervous 
System.  Here  will  be  considered  only  the  exudative  and  the  lymphatic 
diatheses. 

EXUDATIVE  DIATHESIS 

Etiology. — This  title  was  applied  by  Czerny^  to  subjects  in  which, 
with  other  symptoms,  there  is  a  tendency  to  exudation,  or  inflammation, 
of  the  skin  and  mucous  membrane.  It  covers  many  of  the  symptoms 
formerly  described  as  "scrofulous,"  but  is  in  no  way  connected  etio- 
logically  with  tuberculosis.  It  occurs  chiefly  in  the  1st  year  of  hf  e,  but  to  a 
lesser  extent  after  this  period.  It  is  to  a  considerable  extent  hereditary 
and  familial,  several  children  of  the  family  exhibiting  the  same  symptoms, 
and  the  parents  perhaps  having  suffered  from  eczema,  gout,  asthma, 
or  some  nervous  disorder.  Apart  from  the  constitutional  tendency, 
the  symptoms  are  brought  on  or  increased  by  an  improper  diet,  such  as 
one  containing  an  excess  of  food  of  any  sort,  especially  one  too  largely  of 
milk,  and,  most  of  all,  of  fat. 

Symptoms.^ — The  disease  manifests  itself  in  infancy  by  an  unusual 

disposition  to  the  development  of  seborrhea  of  the  scalp  and  face,  and 

later  of  eczema;  the  latter  often  extending  over  much  of  the  body. 

Catarrhal  inflammation  of  the  nose  and  pharynx,  as  well  as  bronchitis, 

Mahrb.  f.  Kinderh.,  1905,  LXI,  199. 


THE  DIATHESES  631 

is  common,  and  otitis  a  frequent  consequence.  Some  enlargement  of 
the  neighboring  lymphatic  glands  may  be  found,  but  decided  and  exten- 
sive hypertrophy  is  not  a  characteristic  of  this  disease.  The  infants  are 
usually  plump,  but  flabby  and  anemic.  Elevation  of  temperature  occurs 
readily.  In  other  cases  they  are  thin  even  before  symptoms  appear,  or 
become  debilitated  and  lose  flesh  through  the  constant  irritation  and  loss 
of  sleep  brought  about  by  the  itching  of  an  eczema.  The  blood  shows  an 
increase  of  the  eosinophilic  cells,  perhaps  up  to  10  or  20  per  cent.  Whether 
this  depends  upon  eczema,  of  this  is  present,  or  occurs  coincidentally  and 
from  the  same  cause,  is  uncertain.  The  fact  that  it  is  seen  in  asthma 
also  is  suggestive  of  the  latter  relationship.  It  has  been  claimed  that 
the  sugar-content  of  the  blood  and  the  retention  of  chlorides  is  increased, 
but  this  demands  further  proof. 

In  older  children,  after  the  period  of  infancy,  eczema  may  be  replaced 
by  asthma,  obstinate  cough,  pruritis,  lichen,  and  urticaria.  The  geo- 
graphical tongue  is  a  common  symptom.  Vasomotor  disturbances  are 
frequent,  such  as  palpitation,  rises  of  temperature,  and  the  like.  It  is 
uncertain  whether  the  phlyctenules  which  appear  on  the  conjunctiva  in 
children  are  symptoms  of  the  exudative  diathesis,  or  are  actual  tuber- 
culous lesions. 

In  the  category  of  the  exudative  diathesis  perhaps  belong,  too,  many 
of  the  cases  of  arthritism  in  children,  described  by  Comby^  and  others. 
The  symptoms  are  variable  and  multiform.  Prominent  among  them  are 
those  just  detailed,  in  addition  to  attacks  of  vomiting  (recurrent  vomiting) 
and  various  other  nervous  and  vasomotor  disturbances. 

Course  and  Prognosis. — The  tendency  to  eczema  diminishes  greatly 
after  the  1st  year,  and  in  general  the  exudative  symptoms  are  prone  to 
ameliorate  and  soon  to  cease.  Sometimes,  however,  the  symptoms 
characteristic  of  the  condition  after  this  period  are  very  slow  in  dis- 
appearing. Generally  they  are  gone  by  the  time  puberty  is  reached. 
They  do  not  often  in  themselves  constitute  an  element  of  danger.  Fatal 
results  generally  depend  upon  an  attendant  spasmophilic  or  lymphatic 
diathesis. 

Diagnosis. — This  rests  upon  the  symptoms  as  already  outlined. 
Scrofulo-tuberculosis  may,  it  is  true,  develop  in  children  with  the  exuda- 
tive diathesis,  but  the  eczema  and  catarrhal  condition  of  the  latter  has 
nothing  in  common  with  the  glandular  inflammation,  chronic  conjunc- 
tivitis and  keratitis,  and  severe  chronic  catarrhal  processes  of  the  former; 
although  it  is  possible  that  it  is  the  existence  of  the  exutlative  condition 
which  predisposes  to  a  tuberculous  infection  producing  the  symptoms 
often  called  scrofula.  Similarly  the  status  lymphaticus  is  characterized 
by  decided  hypertrophy  of  the  lymphatic  tissues  throughout  the  body, 
inclu(Hng  the  thynuis  gland,  and  by  a  tendency  to  sudden  death;  but  it  is 
not  a  pro(hiccr  of  eczema  or  catarrhal  processes.  It  is,  liowevor,  fre- 
quently combined  with  the  exudative  diathesis. 

Treatment.  -Only  the  j^assing  of  time  will  cure  the  constitutional 
predisposition,  and  treatment  must  be  dircM'ted  against  the  inmuHliate 
exciting  cause  of  the  symptoms.  This  is  chiefly  dietetic.  The  fat  in  the 
food  must  l)e  reduced,  and  indeed  the  total  amount  of  food  given  usually 
diminished  as  well,  and  care  taken  to  prevent  the  children  from  gaining 
weight  rapidly.  Starch}'  addition  to  the  diet  should  be  commenced  at 
once  on  the  apjx'arancc;  of  .symptoms,  and  this  made  to  replace  niilU  to  a 
considerable  extent. 

I  Arrli.  (le.  imul.  dcs  t-nf..  1«»()2,  \,  1 ;  (>."». 


632  THE  DISEASES  OF  CHILDREN 

LYMPHATIC  DIATHESIS 
(Lymphatism.     Status  Lymphaticus) 

This  is  a  disorder  much  discussed  and  not  yet  entirely  understood. 
It  would  appear  to  be  a  constitutional  condition  in  which  there  is  present 
a  diminished  resistance  of  the  entire  organism  to  morbid  influences,  and 
a  certain  hypersensitiveness  of  the  nervous  system  producing  a  predis- 
position to  sudden  death  from  cardiac  failure  brought  on  by  slight  and  in 
themselves  insufficient  causes,  or  occurring  entirely  unexpectedly  and 
apparently  without  reason.  Anatomically  there  is  a  tendency  to  general 
hyperplasia  of  the  lymphoid  tissues  throughout  the  body,  including,  the 
thymus  gland.  The  close  association  of  lymphatism  with  sudden  death 
and  thymic  enlargement  was  emphasized  by  Paltauf;i  while  Escherich^ 
maintained  that  the  condition  was  a  toxemia,  the  origin  of  which  was 
the  hypertrophied  thymus  gland.  The  relative  relationship  of  thymic 
hypertrophy  and  of  general  lymphatic  enlargement  is  not  yet  clear.  It 
is  possible  that  lymphatic  overgrowth  is  the  direct  cause  of  the  symptoms, 
and  that  the  enlargement  of  the  thymus  gland  is  an  accidental  or  a  com- 
pensatory process.  Whether,  however,  a  lymphoid  hyperplasia  is  a 
necessary  condition,  or  even  one  always  present  has  been  disputed ;  and  the 
theory  has  been  advanced  by  Heubner^  and  others,  and  has  much  in  its 
favor,  that  the  disorder  is  a  constitutional  anomaly  consequent  upon  some 
chemical  alteration  of  the  tissues,  independent  of  lymphatic  or  thymic 
enlargement,  although  these  may  appear  among  the  later  symptoms. 
Personal  experience  has  led  me  to  the  belief  that  the  enlargement  of  the 
thymus,  and  perhaps  too  of  the  lymphatic  glands,  is  a  secondary  matter, 
and  can  be  entirely  absent  in  cases  of  sudden  death,  and  present  in  those 
dying  of  other  causes.  (See  also  Sudden  Death,  p.  216,  and  Enlarge- 
ment of  the  Thymus,  Vol.  II,  p.  518.) 

There  are  cases  with  glandular  enlargement  and  symptoms  of  other 
sorts  to  which  the  title  "scrofulous"  was  formerly,  and  is  still  often,  ap- 
plied, the  lesions  being  in  reality  tuberculous  manifestations,  although 
the  constitutional  condition  would  place  the  child  in  the  class  of  those 
suffering  from  the  lymphatic  or  oftener  from  the  exudative  diathesis  (p. 
630.  See  also  Tuberculosis,  p.  559,  and  Adenitis,  Vol.  II,  p.  249.)  There 
is  an  undoubted  close  relation  between  lymphatism  and  spasmophilia  (see 
Vol.  II,  p.  249)  on  the  one  hand,  and  the  exudative  diathesis  on  the  other. 

Etiology .^ — A  distinct  family  disposition  is  seen  in  many  instances. 
A  tendency  to  glandular  swelling  may  have  existed  in  the  parents  as  well 
as  the  children;  and  as  regards  the  most  severe  form,  I  have  previously 
reported"*  the  occurrence  of  9  sudden  deaths  from  lymphatism  in  one 
family  of  children.  The  disease  is  observed  especially  in  infancy  and  early 
childhood,  although  in  the  disposition  to  sudden  death  from  slight  causes 
it  has  not  infrequently  been  witnessed  in  adult  life.  Even  the  new  born 
and  very  young  infants  may  exhibit  it;  and  many  instances  have  been 
wrongly  attributed  to  death  from  suffocation  through  overlying  or 
brought  about  in  other  ways.  Sex,  race  and  season  exert  no  influence. 
Rickets  is  often  associated  with  the  lymphatic  diathesis,  but  has  no  etio- 
logical connection,  other  than  that  both  may  possibly  be  produced  by 
allied    causes  acting  simultaneously  and  consequently  combined;  and 

1  Wien.  klin.  Wochenschr.,  1889,  No.  46;  1890,  No.  9. 

2  Berliner  klin.  Wochenschr.,  1896,  XXXIII,  645. 

3  Ivinderheilkunde,  1911,  33. 

*  New  York  Med.  Journ.,  1909,  Sept.  4. 


THE  DIATHESES  633 

the  same  is  true  of  spasmophilia  and  of  the  exudative  diathesis.  The 
constitutional  tendency  may  be  present  at  birth,  or  may  be  acquired 
especially  through  errors  in  hygiene  and  diet;  or  may  disappear  under 
regulation  of  these  or  perhaps  as  a  result  of  increasing  age. 

Pathological  Anatomy. — The  noteworthy  feature  often  found  at 
autopsy  is  the  hyperplasia  of  lymphoid  tissue.  This  is  seen  especially 
in  the  thymus  gland,  which  is  frequently  abnormally  large.  In  determin- 
ing the  existence  of  enlargement  the  great  variation  in  the  size  of  the  nor- 
mal thymus  gland  in  different  children  is  to  be  taken  into  account,  as  well  as 
the  age  of  the  patient.  (See  Phj^siology,  p.  62;  Diseases  of  the  Thymus 
Gland,  Vol.  II,  p.  518.)  In  addition  to  this  lesion  there  is  commonly  more 
or  less  hj^pertrophy  of  the  lymphoid  tissue  throughout  the  body,  particu- 
larly well  seen  in  the  glands  of  the  neck  and  head,  and  in  the  tracheo- 
bronchial and  mesenteric  glands,  as  also  in  the  nasopharjaix,  the  posterior 
pharyngeal  wall,  the  base  of  the  tongue,  the  tonsils,  the  entrance  to  the 
larynx,  Peyer's  patches,  and  the  solitary  follicles  of  the  intestine.  There 
is  usually  moderate  enlargement  of  the  spleen,  with  prominence  of  the 
Malpighian  bodies.  The  liver  is  often  fatty  and  the  cardiac  muscle  may 
show  degeneration.  In  determining  the  presence  of  abnormal  Ij-mphatic 
overgrowth,  the  natural  tendency  of  all  normal  children  to  a  certain  degree 
of  this  is  to  be  taken  into  account. 

Symptoms. — These  are  often  vague  or  even  unnoticed;  often 
sufficiently  well  marked,  but  varied.  The  frequent  association  of  the 
exudative  diathesis  accounts  for  the  tendency  to  seborrhea  and  eczema 
so  often  seen.  Lymphoid  hypertrophy  is  generally  discovered  in  some 
part  of  the  body.  It  is  often  and  sometimes  early  shown  in  the  develop- 
ment of  adenoid  growths  of  the  nasopharjmx,  or  increase  of  lymphoid 
tissue  at  the  base  of  the  tongue  or  on  the  posterior  pharyngeal  wall.  In 
other  cases  there  may  be  discovered  persistent  and  sometimes  decided 
enlargement  of  the  lymphatic  glands  in  the  region  of  the  neck,  occiput, 
axillae,  or  groins.  The  spleen  is  often  found  enlarged  on  palpation,  and 
it  may  be  possible  to  detect  by  percussion  or  by  radiography,  or  occasion- 
ally by  palpation,  an  enlargement  of  the  thymus  gland.  Generally, 
however,  thymic  enlargement  cannot  be  satisfactorily  determined  during 
life.  (See  Diseases  of  the  Thymus  Gland,  Vol.  II,  p.  518.)  Other  cases 
show  a  tendency  to  asthmatic  respiration  or  1  o  attacks  of  asphyxia  depend- 
ent sometimes  upon  pressure  of  an  enlarged  thymus  gland;  much  oftcner 
upon  the  nervous  disturbance.  Ordinary  asthmatic  bronchitis  is  a  symp- 
tom rather  of  the  exudative  diathesis.  The  combination  of  the  neuro- 
pathic diathesis  or  of  spasmophilia  frequently  observed  accounts  for  the 
occurrence  of  convulsions,  dyspnea,  fever  from  insignificant  causes,  and 
laryngospasm ;  but  it  is  not  certain  how  often  this  is  the  case  and  how 
many  instances,  especially  of  the  last  mentioned,  depend  purely  upon  lym- 
phatism.  The  children  are  usually  phlegmatic.  flal)by,  fat,  inactive,  pale, 
and  of  little  strength.  There  is  a  very  notably  diminished  resisting  power 
and  increased  susceptibility  to  disease,  and  infections  of  any  sort  may 
produce  an  unusually  well-marked  reaction. 

Of  all  symptoms,  however,  the  most  imjiortant  is  the  danger  of  sud- 
den death.  This  often  appears  to  be  resj^ratory  from  asphyxia  and 
cyanosis,  but  probably  in  most  ca.ses  is  cardiac,  as  was  pointed  out  by 
Pott,*  the  accident  occurring  without  discoverable  reason;  or  following 
very  insignificant  trauma,  such  as  a  hypodermic  injection,  an  exploratory 

» Jahrb.  f.  Kindcrh.,  1892,  XXXIV,  US. 


634  THE  DISEASES  OF  CHILDREN 

puncture,  the  giving  of  diphtheria  antitoxin,  and  the  Hke;  or  being  pro- 
duced by  the  shock  from  cold  water,  the  use  of  a  tongue-depressor,  the 
administration  of  an  anesthetic,  or  the  occurrence  of  some  mild  acute 
disease;  or  often  without  there  having  been  any  previous  symptoms  what- 
ever. In  any  event  the  patient  suffers  from  a  sudden,  apparently  suffo- 
cative attack,  throws  the  head  back,  turns  pale,  or  perhaps  bluish,  and 
perhaps  dies  in  an  instant;  or  the  child  ma}''  possibly  be  found  dead  in  bed 
without  any  symptoms  having  been  observed.  Sometimes  the  death  is 
not  entirely  without  warning,  and  attacks  which  appear  to  be  laryngo- 
spasm,  or  sj^mptoms  suggesting  asphyxia  from  other  causes,  may  be  present 
for  several  hours.  In  still  other  instances  there  may  have  been  a  series 
of  short  attacks  of  the  nature  described  occurring  during  some  weeks  or 
longer,  and  the  patient  at  last  dies  in  one  of  these.  I  have  known  such 
short  attacks  to  be  of  very  great  frequency.  Thus  in  one  case  the  mother, 
a  foreigner  with  little  command  of  English,  said  of  her  child  that  it  "died 
every  day."  Probably  the  majority  of  cases  of  lymphatism  of  this  severest 
form  are  not  recognized  until  a  sudden  fatal  attack  occurs. 

Prognosis.^ — For  the  milder  cases  the  prognosis  is  on  the  whole  good, 
if  dangerous  symptoms  can  be  avoided.  Under  proper  management  the 
evidences  of  the  disease  may  be  kept  in  abeyance,  and  even  the  patho- 
logical tendency  made  to  disappear  as  the  patient  grows  older,  and  par- 
ticularly as  puberty  is  approached.  On  the  other  hand,  the  prognosis 
is  always  doubtful  in  individual  cases,  because  of  the  possibility  of  the 
occurrence  of  sudden  death. 

Diagnosis. — This  can  be  made  if,  with  the  symptoms  described, 
the  distinct  evidences  of  lymphatic  hyperplasia  are  discoverable.  An 
rc-ray  examination  may  show  hypertrophy  of  the  thymus  gland.  Dis- 
covery b}^  the  same  means  of  enlarged  tracheo-bronchial  lymph-nodes  does 
not  determine  whether  these  are  dependent  upon  tuberculosis  or  upon 
the  lymphatic  diathesis.  Similarly  the  hypertrophy  of  the  tonsillar  tissue 
of  the  fauces  and  nasopharynx  is  not  by  itself  sufficient  to  warrant  a 
diagnosis  of  lymphatism,  although  it  is  a  characteristic  of  this  condition. 
Often,  in  fact,  lymphatism  is  entirely  unsuspected  until  sudden  death 
occurs  and  autopsy  shows  general  hypertrophy  of  the  lymphatic  tissue 
of  the  body. 

Treatment. — The  only  treatment  possible  is  the  careful  regulation 
of  the  diet  and  hygiene,  inasmuch  as  it  is  very  probable  that  these,  and 
particularly  the  diet,  have  a  decided  etiological  influence.  There  is  no 
rule,  however,  which  indicates  what  the  alteration  in  the  diet  should  be, 
and  possible  faults  should  be  sought  for  in  each  individual  case.  Gym- 
nastic exercises  and  massage  may  improve  the  general  health.  Suitable 
tonics  may  be  employed  to  increase  the  patient's  strength  and  remove 
anemia.  Whenever  the  lymphatic  diathesis  is  suspected,  great  care 
must  be  taken  to  avoid  the  causes  which  bring  about  a  sudden  fatal 
termination.  The  use  of  an  anesthetic  must  be  refrained  from  if  it  can 
be  avoided,  and,  indeed,  no  operation  performed  which  can  in  any  way  be 
omitted.  Cool  bathing  may  be  dangerous,  as  may  any  other  sudden 
physical  or  mental  shock.  Even  the  giving  of  antitoxin  is  to  be  regarded 
with  anxiety,  and  the  objections  to  it  must  be  carefully  weighed  before  a 
decision  is  reached. 


ACIDOSIS  635 

CHAPTER  VII 
ACIDOSIS 

By  this  term  is  designated  the  condition  in  which  acid-substances  are 
present  in  the  blood  in  a  quantity  relatively  so  increased,  that  the  normal 
excess  of  alkali  is  much  diminished.  Experimentally  acidosis  with  its 
symptoms  has  been  caused  in  rabbits  by  the  administration  of  hydro- 
chloric acid  in  large  amounts.  In  man  it  depends  upon  a  relative  excess 
of  acid  produced  in  the  economy.  These  acids  are  in  some  cases  repre- 
sented by  the  acetone  bodies,  and  consist  of  l3-oxybutyric  acid,  aceto- 
acetic  acid,  and  acetone.  In  other  instances,  as  in  the  acidosis  of  diarrhea 
in  infancy,  it  is  certain  that  these  bodies  play  no  part  whatever,  and  that 
there  is  little  or  no  increase  of  them  in  the  blood.  Acid-substances  of 
other  nature  are  operative  here. 

The  relative  excess  of  acid  in  the  blood  may  be  due  either  to  an  over- 
production of  acid-bodies ;  to  a  failure  of  the  lungs  and  kidneys  to  excrete 
them  in  sufficient  amount;  or  possibly  to  a  loss  of  bases  from  the  body 
(Howland  and  Marriott).^  Thus  the  removal  of  alkali  from  the  system 
might  produce  acidosis,  as  well  as  the  formation  of  an  excess  of  acids. 

The  acetone-bodies  are  normally  present  in  small  amount  in  the  blood 
and  urine  of  healthy  children,  as  shown,  among  others,  by  Moore- 
and  by  Veeder  and  Johnson.^  The  amount  is  increased  in  starvation, 
acute  febrile  diseases,  severe  diarrhea,  diabetes,  intestinal  autointoxica- 
tion, and  recurrent  vomiting.  The  presence  of  an  excess  of  these  in  the 
urine  may  or  may  not  be  accompanied  by  symptoms  of  acidosis.  The 
term  "acidosis"  denotes  a  decrease  in  the  alkalinity  of  the  blood,  as 
indicated  by  diminished  carbonic  dioxide  tension  of  the  alveolar  air,  an 
increase  in  the  hydrogen-ion  concentration  of  the  blood,  a  great  lessening 
of  the  alkali  reserve  of  the  blood,  and  an  increase  of  the  ammonia  of  the 
urine.  These  constitute  a  disturbance  of  the  normal  balance  between  the 
acid  and  the  alkali  of  the  blood. 

A  sharp  distinction  must  therefore  be  drawn  between  acetonuria  and 
acidosis.  This  is  necessary  on  account  of  the  wide-spread  confusion 
which  has  arisen,  according  to  which  acidosis  is  supposed  to  be  always 
indicated  by  acetonuria.  Acetonuria  consists  merely  in  the  presence 
of  acetone-bodies  in  the  urine.  It  is  a  matter  of  excretion,  and  may 
or  may  not  be  accompanied  by  symptoms  of  acidosis.  Acido.sis,  on  the 
other  hand,  as  has  been  stated,  is  characterized  by  a  relative  decrease  in 
the  alkalinity  of  the  blood,  independent  of  the  amount  of  the  acetone 
bodies  wliicli  is  being  excreted.  It  may  occur  without  the  presence  of 
any  of  these  bodies  in  the  urine,  and  may  depend  upon  other  acid- 
substances;  possibly  acid  phosphate,  lactic  acid,  or  the  like.  It  is  only 
by  the  presence  of  characteristic  symptoms  and  by  laboratory  tests  that 
the  diagnosis  of  acidosis  can  l)e  made  with  certainty.  Errors  in  diagnosis 
are  frccjuent,  on  account  of  the  misconception  of  this  contrast.  Any 
starving  ciiild,  as,  for  instance,  one  witii  repeated  vomiting  and  the 
conse(iuent  emi)tiness  of  the  stomach,  exhil)its  an  increas(>d  amovmt  of 
the  acetone-l)()(li(\s  in  the  urine;  and  liiis  has  been  wrongly  assumed  to  l)e 
the  proof  of  the  existence  of  acidosis.     So,  too,  a  large  pioportion  of 

'  .ViiKT.  .Jomii.  Dis.  Child.,  lOIfi,  XI,  30i). 
"  .\nier.  .Journ.  Di.s.  Child.,  1910,  XII,  244. 
'  Amor.  Journ.  Di.s.  Child.,  IDKi,  XI,  291. 


636  THE  DISEASES  OF  CHILDREN 

cases  of  acute  febrile  disorders  in  early  life  exhibit  a  decided  acetonuria,       | 
but  without  suffering  in  any  way  from  acidosis. 

On  the  other  hand,  it  is  certainly  true  that  children  are  especially 
predisposed  to  the  development  of  acidosis.     This  depends  either  upon 
the  smaller  reserve  of  alkali  which  they  possess,  or  upon  the  readiness       ' 
with  which  their  organism  produces  the  acetone-bodies,  without  any 
discoverable  explanation. 

Acidosis  is  a  common  symptom  in  diabetes  at  any  age.     In  early  life       ■ 
this  disease  is  a  less  frequent  etiological  factor  merely  on  account  of  its       : 
less  frequent  occurrence ;  since  a  most  dangerous  acidosis  develops  with  the       ; 
greatest  suddenness  and  facility  in  diabetes  in  children.     A  much  more       : 
common  cause  is  severe  diarrhea,  especially  of  the  class  of  "food  intoxica-       ' 
tion,"  "cholera  infantum,"  "summer  diarrhea,"  and  the  like,  in  which       j 
rapid  and  profuse  loss  of  hquid  and  of  the  bases  of  the  body  takes  place 
from  the  intestine.     This  is  a  form  of  the  disease  clearly  not  dependent 
upon  the  production  of  any  excess  of  the  acetone-bodies  in  the  blood. 
Just  what  etiological  relationship  the  retention  of  acid  phosphate  may 
possess  appears  uncertain.  i 

Acetonuria  is  a  frequent  symptom,  too,  in  recurrent  vomiting,  but  ' 
would  appear  to  be  oftener  a  result  of  the  starvation  than  an  indi- 
cation that  acidosis  is  the  cause  of  this  disease,  especially  as  vomit-  i 
ing  is  not  a  characteristic  symptom  of  acidosis.  The  exact  relation- 
ship of  acidosis  to  recurrent  vomiting  does  not  as  yet  appear  to  be  fully  \ 
determined.  (See  Recurrent  Vomiting,  p.  701.)  The  disease  is  appar-  j 
ently  due  to  some  intoxication,  and  this  may  be  an  acidosis,  but  the  i 
presence  of  acetonuria  is  no  proof  of  it. 

Pneumonia  and  nephritis  may  be  productive  of  acidosis,  and  it  is 
very  probable  that  many  of  the  symptoms  denominated  uremic  may  be, 
in  reality,  dependent  upon  an  acid  intoxication.  Finally  severe  acidosis 
may  occasionally  develop  without  any  discoverable  reason  whatever. 

There  are  certain  symptoms  which  are  suggestive  of  the  disorder. 
Among  the  earliest  of  these  may  be  mentioned  restlessness,  sleeplessness, 
excitement;  and  later  a  tendency  to  prostration,  somnolence,  and  coma. 
When  these  appear  in  a  case  of  diabetes,  or  in  an  infant  with  severe  sum- 
mer diarrhea,  and  decided  oliguria,  acidosis  can  with  reason  be  suspected. 
The  only  positive  symptom,  however,  apart  from  laboratory  tests,  is 
hyperpnea.  This  consists  in  a  remarkable  alteration  of  respiration, 
with  deep  and  exaggerated  inspiration  and  expiration,  usually  not  in- 
creased in  rapidity,  and  constantly  present;  yet  without  any  functional 
or  organic  disorder  of  the  lungs  or  heart  to  account  for  this,  and  without 
cyanosis.  The  degree  of  hyperpnea  is  directly  proportional  to  the 
reduction  of  the  alkali  reserve  of  the  blood,  as  shown  by  laboratory  tests. 

The  prognosis  is  in  most  cases  unfavorable.  If  once  the  symptoms 
are  well  developed,  death  is  liable  to  occur.  The  relief  of  coma  and  of 
hyperpnea  may  be  effected  at  least  temporarily,  but  with  only  a  deferring 
of  the  fatal  issue.  Coma  may  return  and  death  result  without  the 
redevelopment  of  any  urinary  symptoms  to  account  for  it. 

The  treatment  should  be  'preventive.  If  any  diseased  condition  exists 
in  which  it  is  known  that  there  is  danger  of  acidosis  developing,  the  occur- 
rence of  the  symptoms  must  be  carefully  guarded  against.  In  diabetes  the 
greatest  caution  must  be  observed  in  the  removal  of  the  carbohydrates  from 
the  diet,  without  a  simultaneous  cutting  off  of  the  protein,  and  especially 
of  the  fat.  Starvation  is  the  procedure  indicated  for  the  beginning  of 
treatment.     In  the  case  of  severe,  profuse,  diarrheal  discharges  in  infancy, 


DIABETES  MELLITUS  637 

prompt  means  must  be  taken  to  check  the  loss  of  hquid  from  the  system. 
Initial  purgation  in  such  cases  is  dangerous,  and  astringents  and  opium 
should  be  used  at  once,  unless  the  presence  of  fever,  tympanites,  and  the 
character  of  the  stools  indicate  that  irritating  substances  are  still  present 
in  the  intestinal  canal.  In  all  cases  where  acidosis  is  feared  there  should 
be  a  prompt  administration  of  alkali,  especially  bicarbonate  of  soda, 
in  sufficient  amount  to  render  the  urine  alkaline.  It  may  be  given  by 
the  mouth  or  by  the  bowel.  Even  in  cases  where  well-marked  symptoms 
of  acidosis  are  already  present,  efforts  should  be  made  to  restore  the 
alkali  reserve  of  the  blood,  the  production  of  alkalinity  of  the  urine  being 
the  indication  of  the  success  attained.  In  normal  infants  2  to  3  grams 
(0.07  to  0.11  oz.)  of  bicarbonate  of  soda  is  sufficient  to  render  the  urine 
alkaline;  but  when  acidosis  is  present  from  4  to  10  times  this  amount 
may  be  required  (Rowland  and  Marriott).^  In  urgent  cases  it  is 
best  to  administer  the  soda  intravenously,  using  a  4  per  cent,  solution, 
and  giving  at  one  time  75  c.c.  (2.5  fl.  oz.),  or  more  in  infancy;  the  determi- 
nation of  the  amount  and  of  the  number  of  injections  being  decided  by  the 
production  of  urinary  alkalinity.  The  solution  for  this  purpose  should 
be  prepared  by  a  special  method,  since  the  process  of  sterilization  decom- 
poses the  sodium  bicarbonate  and  renders  the  solution  very  irritating. 
(See  p.  232.)  In  spite  of  care,  however,  sloughing  of  the  tissues  may  occur, 
if  any  of  the  fluid  escapes  into  them.  The  subcutaneous  injection  of  the 
fluid  is  to  be  deprecated,  as  damage  to  the  tissues  is  extremely  likely  to 
follow,  even  with  the  specially  prepared  solution.  It  is  true  that  there 
is  danger  of  the  administration  of  alkali  in  excess,  even  when  checked  by 
repeated  examinations  of  the  reaction  of  the  urine;  but  the  danger  appears 
to  be  decidedly  less  than  that  caused  by  the  persistence  of  the  acidosis. 

In  addition  to  the  treatment  by  alkalis  the  administration  of  water 
in  large  amount  is  important  in  all  cases,  and  especially  in  those  in  which 
there  has  been  a  large  loss  of  liquid  from  the  system  through  the  presence 
of  diarrhea.  If  this  cannot  be  given  by  the  mouth,  or  if  not  retained  by 
the  rectum,  it  may  be  administered  in  the  form  of  normal  saline  solution, 
either  by  hypodermoclysis  or,  better,  by  intraperitoneal  injection. 


CHAPTER  VIII 
DIABETES   MELLITUS 


Only  the  salient  features,  especially  as  applied  to  children,  can  be 
discussed  in  this  connection.  Althougli  known  to  the  ancients  it  was  first 
clearly  distinguished  from  diabetes  insipidus  by  Willis.-  Although  much 
less  frecjuent  in  eaily  life  than  later,  my  own  experience  accords  with  that 
of  those  who  find  it  occurring  at  this  titne  much  oftener  than  formerly 
supposed,  or  than  many  statistics  would  indicate.  It  is  to  he  distinguished 
from  alimentary  glycosuria  and  transitoiy  glycosuria  from  othei'  causes. 
(See  Vol.  II,  p.  1(58.)  Very  prol)al)ly  the  statistics  of  diabetes  in  children 
include  many  instances  which  belong  to  this  class  of  cases.  A  character- 
istic distinction  is  that  pointed  out  by  Allen,''  that  whereas  in  non-diabetics 
the  ingestion  of  carbohydrates  in  excess  increases  the  amount  which  can  be 

'  Lnc.  rit. 

-  Pharinaccuf.   ration.,    1(171,   S<'(t.    1\',    (\ip.    HI.      Ref.,  Senator  in  Zii'nini.son's 
Handb.  d.  spvc.  Path.  u.  Tlicrai).,  IStiT,  XIII,  2,  117. 
'  Glvcusuiia  and  Diabetes,  l<)i;i,  1050. 


638  THE  DISEASES  OF  CHILDREN 

utilized  by  the  subject,  in  diabetics  the  tolerance  diminishes  in  propor- 
tion as  the  amount  of  carbohydrate  is  increased. 

Etiology. — Age  is  an  important  factor,  von  Noorden,'  found  in 
3000  cases  of  diabetes  2.8  per  cent,  occurring  in  the  first  10  years  of  life. 
The  report  of  the  Registrar  General  for  England  and  Wales  from  1861 
to  1870  inclusive  gave  a  very  similar  percentage  (Dickinson).-  In  6494 
deaths  from  diabetes  there  were : 

Table  79. — Mortality  from  Diabetes  in  Early  Life, 
England  and  Wales 

Under  1  year 8 

1  year  old 19 

2  j^ears  old 16 

3  years  old 15 

4  years  old 16 

Total  under  5  years 74  (1 . 1  %) 

5  to  10  years 114 

Total  under  10  years 188  (2 . 9%) 

10  to  15  years 200  (3.0%) 

Joslin's^  statistics  show  a  larger  number;  4.7  per  cent,  of  his  1156  cases 
having  commenced  in  the  first  10  years  of  life.  The  majority  of  deaths 
in  early  life  occur  after  the  age  of  5  years,  and  especially  from  10  to  14 
years  of  age.  The  statistics  given  show,  however,  that  infants  even  in  the 
1st  year  are  attacked.  The  youngest  cases  under  my  care  were  in 
girls  of  15  and  161^  months  respectively.  Knox"*  collected  16  cases  in  the 
1st  year  of  life.  In  Stern's  statistics^  of  117  collected  cases  in  children, 
6  were  under  1  year  of  age,  and  in  1  of  these  the  disease  appeared  to  be 
congenital.  Such  a  case  appears  to  be  that  of  Cuno^  of  pancreatic 
diabetes  in  a  child  of  3  weeks.  In  Wegeli's^  108  collected  cases  in  children, 
not  included  in  Stern's  series,  there  were : 

Table  80. — Incidence  of  Diabetes  in  Early  Life 

Under  1  year 3  cases 

1  to  5  years 26  cases 

5  to  10  years 31  cases 

10  to  16  years 42  cases 

In  adult  life  diabetes  is  distinctly  more  common  in  males  than  in 
females,  but  in  children  sex  appears  to  have  but  little  influence.  He- 
redity  plays  a  very  important  part,  the  disease  having  shown  itself  in  the 
parents  or  grandparents,  or  more  than  one  of  the  children  being  attacked. 
This  is  true  in  from  10  to  25  per  cent,  of  the  published  statistics.  Consan- 
guinity, gout,  nervous  disorders,  tuberculosis  and  syphilis  of  the  parents 
have  also  been  considered  causes.  Trauma  of  the  head  and  intracranial 
tumors,  especially  of  the  medulla,  have  been  followed  by  the  disease.  An 
excessive  consumption  of  sugar  sometimes  results  in  a  permanent  glyco- 
suria. Diabetes  occasionally  follows  acute  diseases  or  nervous  shock. 
Probably,  however,  the  majority  of  cases  are  associated  with  lesions 
or  disturbance  of  function  of  the  pancreas. 

1  Pfaundler  u  Schlossmann,  Handb.  d.  Kinderheilk.,  1910,  II,  117. 

2  Diabetes,  1875,  66. 

3  Treatment  of  Diabetes  Mellitus,  1917,  28. 

«  Johns  Hopkins  Hosp.  Bull.,  1913,  XXIV,  274. 
5  Arch.  f.  Kinderh.,  1889-90,  XI,  82. 
«  Jahrb.  f.  Kinderh.,  1910,  LXXI,  623. 
7  Archiv  f.  Kinderh.,  1895,  XIX,  1. 


DIABETES  MELLITUS  639 

Symptoms. — These  do  not  differ  materially  from  those  in  adult 
life,  except  that  the  onset  is  frequently  more  rapid  and  the  course  shorter. 
The  chief  sjrmptoms  consist  in  wasting,  thirst,  great  appetite,  and 
excessive  secretion  of  urine  containing  glucose.  In  the  beginning,  and 
perhaps  during  several  months,  the  symptoms  are  but  little  marked,  and 
only  unusual  thirst  or  abundant  secretion  of  urine,  or  moderate  loss  of 
weight  and  strength  are  noticed.  The  child  does  not  seem  ill  in  other 
respects  and  is  decidedly  improved  by  dietetic  treatment.  After  a 
variable  time  the  symptoms  increase  in  severity.  The  thirst  is  very  great 
and  a  surprising  amount  of  water  is  drunk;  the  appetite  is  sometimes 
voracious,  sometimes  diminished;  the  tongue  is  red  and  drj'-;  the  teeth 
decay  readily;  the  skin  is  dry  and  harsh  and  usually  somewhat  pale, 
dependent  upon  the  anemia  which  is  generally  present.  Perspiration  is 
diminished  or  absent.  Constipation  is  frequent.  Nocturnal  incon- 
tinence of  urine  is  a  common  and  often  an  early  symptom.  There  is 
decided  debility  and  the  patient  becomes  very  easily  exhausted  and  suffers 
from  loss  of  spirits,  irritabilitj^,  headache  and  diffuse  pains.  Wasting  is 
progressive  and  rapid  and  finally  becomes  extreme. 

As  regards  the  character  of  the  urine,  the  total  secretion  often  reaches 
3  or  4  times  the  normal  amount,  exceptionally  even  equalling  6  or  8 
quarts  (5672  or  7563)  in  24  hours.  It  is  pale  in  color,  acid,  and  with  the 
specific  gravity  ranging  from  1025  to  even  1050,  although  occasionally 
it  may  not  be  over  1015.  The  percentage  of  sugar  varies  from  a  small 
amount  up  to  5  per  cent,  or  more,  and  even  as  much  as  10  or  12  per  cent, 
has  been  reported.  The  total  quantity  of  sugar  excreted  in  24  hours 
may  reach  6  ounces  (170)  or  over.  A  small  amount  of  albumin  is  fre- 
quent with  a  few  casts.  Acidosis  is  a  characteristic  of  the  disease,  seen 
in  all  advanced  cases.  As  it  develops,  acetone,  diacetic  acid  and  /3-oxy- 
butyric  acid  appear  in  the  urine. 

Complications. — These  are  much  less  frequent  than  in  adult  life. 
Epistaxis,  furunculosis,  urticaria,  erythema,  cutaneous  abscesses,  and 
eczema  are  not  uncommon.  Gangrene  is  rarelj^  seen  in  early  life.  Cata- 
ract has  been  reported,  but  is  not  common  at  this  age.  This  is  true 
also  of  optic  neuritis  and  retinitis.  Nephritis  of  moderate  degree  is  not 
infrequent.  Peripheral  neuritis  and  otitis  are  sometimes  seen.  Tuber- 
culosis, or,  oftener,  bronchopneumonia,  is  a  not  unusual  complication. 
Course  and  Prognosis. — The  course  of  diabetes  in  children  is 
usually  more  rapid  than  in  adults.  It  is  rare  that  the  attack  lasts  much 
over  a  year  from  the  time  symptoms  are  discovered,  and  usually  a 
shorter  time.  As  the  earlier  course  of  the  disease  is  seldom  recognized, 
the  total  duration  of  the  affection  is  probably  considerably  longer  tiian 
supposed.  Some  of  the  acute  cases  have  apparently  lasted  only  a  few 
weeks.  I  have  seen  one  instance  in  a  girl  of  4  years  in  which  the  interval 
from  apparently  perfect  health  without  .symptoms  of  any  sort  to  death 
in  coma  eciualled  only  11  days.  Under  ordinary  circumstances  the 
course  is  progressive  if  no  intercurrent  disease  occurs  to  terminate  life. 
Weakness  arul  emaciation  increase  and  finally  coma  develops.  Death  in 
coma  is  especially  frequent  in  children;  that  from  complications  much 
less  often  seen  than  in  adults.  Generally  the  approach  of  coma  is 
indicated  by  loss  of  appetite,  nausea,  vomiting,  epigastric  pain,  the  pres- 
ence of  acetone  in  the  urine  and  its  odor  on  the  breath,  great  weakness  and 
nervous  irritability  with  jactitation,  or  somnolence.  Unconsciousness 
then  comes  on  with  its  characteristic  deep  respiration.  Under  treat- 
ment the  fatal  issue  may  be  delayed,  l)ut  if  coma  has  developed  <leath 


640  THE  DISEASES  OF  CHILDREN 

is  almost  certain  within  a  few  days.  The  final  prognosis  in  children 
is  very  unfavorable,  if  care  be  taken  to  exclude  from  the  list  cases  not 
certainly  diabetes,  such  as  instances  of  transitory  or  alimentary  glycosuria. 
Yet  under  newer  methods  of  treatment  the  prognosis  does  not  appear 
to  be  so  uniformly  bad  as  was  formerly  considered  to  be  the  case,  and  it 
would  appear,  as  pointed  out  by  Riesman^  and  others,  that  the  disease 
at  this  time  of  life  may  sometimes  run  a  mild  course  and  terminate  in 
recovery. 

Diagnosis. — The  disease  would  doubtless  be  oftener  recognized 
were  the  urine  of  infants  and  children  examined  more  systematically. 
The  diagnosis  rests  principal^  upon  the  dryness  of  the  skin,  thirst,  normal 
or  increased  appetite,  loss  of  weight  and  strength,  enuresis,  increased 
secretion  of  urine  and  the  recognition  of  grape  sugar  in  it. 

Diabetes  is  especially  to  be  distinguished  from  other  conditions  in 
which  some  form  of  sugar  is  present  in  the  urine.  Transitory  glycosuria 
following  gastro-intestinal  disturbance  or  attacks  of  infectious  diseases 
may  resemble  it  closely.  It  lasts,  however,  but  a  few  weeks  at  most  and 
is  not  attended  by  the  characteristic  symptoms  of  diabetes.  Alimentary 
glycosuria  also  may  occur  in  certain  individuals  when  an  unusual  amount 
of  sugar  is  contained  in  the  food.  In  the  case  of  infants  lactose  may  some- 
times appear  in  the  urine  under  similar  conditions.  The  reduction  of 
the  amount  of  sugar  given  is  followed  immediately  by  disappearance  of 
the  symptom.  It  must  be  remembered,  too,  that  there  are  other  sub- 
stances besides  sugar  which  will  reduce  the  copper  of  Fehling's  solution. 
Other  tests,  such  as  fermentation,  phenylhydrazin,  or  the  use  of  the 
polariscope,  must  be  employed  before  a  positive  diagnosis  can  be  given 
in  some  cases.  I  have  seen  much  unnecessary  alarm  caused  by  a  too 
hasty  diagnosis. 

Treatment. — This  is  much  the  same  as  in  adult  life  and  need  not  be 
entered  upon  in  full  detail.  It  is  more  unsatisfactory  in  children,  partly 
on  account  of  the  greater  severity  of  the  disease  as  usually  seen  at  this 
time,  partly  owing  to  the  difficulty  in  obtaining  the  cooperation  of  the 
child  in  following  a  strict  diabetic  diet.  The  purpose  of  treatment  is  to 
remove  the  strain  imposed  by  the  secretion  of  sugar,  and  thus  reestablish 
the  lost  tolerance  for  carbohydrates;  the  patient  whose  urine  has  been 
made  sugar-free  having  the  carbohydrates  then  gradually  and  cautiously 
increased,  according  to  the  degree  of  tolerance  obtained.  A  difficulty, 
especially  in  children,  in  the  total  withdrawal  of  carbohydrates  while 
protein  and  fat  are  continued,  is  that  a  condition  of  dangerous  acidosis, 
even  with  the  development  of  coma,  may  be  promptly  produced  in  those 
who  had  not  seemed  in  danger  of  this  condition.  The  plan  of  treatment 
proposed  by  Allen^  has  been  remarkably  successful  in  the  experience  of 
various  clinicians.  It  consists  in  beginning  with  an  almost  complete 
starvation,  giving  only  water,  clear  broth,  and,  if  necessary,  a  small 
amount  of  whiskey;  this  last  especially  if  acidosis  is  present.  This  may 
be  continued  for  not  more  than  3  days,  by  which  time,  in  favorable  cases, 
the  urine  has  become  sugar-free.  This  fasting,  which  would  produce 
acetonuria  in  normal  individuals,  relieves  it  in  diabetes.  Now  small 
amounts  of  food  are  cautiously  given,  preferably  green  vegetables,  such  as 
spinach,  asparagus,  lettuce,  celery,  and  the  like,  containing  from  5  to  6 
per  cent,  of  carbohydrate  (see  Table  by  Joslin),^  and  after  this  protein, 

»  Amer.  Journ.  Med.  Sci.,  1916,  CLI,  40. 

2  Bust.  Med.  and  Surg.  Journ.,  1915,  CLXXII,  241. 

3  Amer.  Journ.  Med.  Sci.,  1915,  CL,  493. 


DIABETES  INSIPIDUS  641 

at  first  in  small  amounts,  and  then  fat.  Not  more  than  from  5  to  10 
grams  (0.18  to  0.35  oz.)  of  carbohydrate  daily  should  be  allowed  at  first,  and 
every  increase  be  made  cautiously.  The  protein,  too,  should  be  at  first 
in  an  amount  of  not  over  20  grams  (0.71  oz.)  per  day.  Frequent  exami- 
nations of  the  urine  for  sugar  and  for  the  acetone  bodies  are  required,  to 
determine  the  tolerance  for  carbohydrates.  Once  a  week  a  day  of  com- 
plete or  partial  fasting  should  be  ordered,  even  if  the  urine  is  sugar-free. 
There  will  be  at  first  a  loss  of  weight,  and  later  but  little  gain  may  take 
place;  but  this  is  a  matter  of  entirely  secondary  consideration.  The 
maintaining  of  a  complete  tolerance  for  carbohydrates  is  the  thing  desired. 
Should  sugar  appear  in  the  urine  the  starvation  must  again  be  instituted; 
but  this  need  not  continue  longer  than  24  hours,  after  which  a  cautious 
return  to  food  should  be  made,  as  at  the  beginning.  Oatmeal  has  been 
recommended  by  Noorden^  as  one  of  the  best  of  the  cereal  foods. 

In  the  case  of  infants  increased  difficulty  arises  owing  to  the  need  of 
milk  in  the  diet.  Sour  milk  may  be  employed  on  account  of  the  dim- 
inished sugar-content;  or  buttermilk  for  the  same  reason,  and  because 
the  diminished  amount  of  fat  aids  in  preventing  the  development  of 
acidosis.     Albumen  water  may  form  part  of  the  diet. 

With  regard  to  the  use  of  drugs,  those  most  in  vogue  are  opium, 
arsenic,  antipyrine,  salicylic  acid,  and  Carlsbad  water.  Amelioration 
appears  to  follow  in  some  instances,  but  the  treatment  of  this  disease  is 
not  by  medicaments.  For  the  prevention  or  treatment  of  diabetic 
coma,  the  administration  of  large  doses  of  bicarbonate  of  soda  is  advised, 
3  to  4  ounces  (93  to  1 24)  or  more  being  given  daily.  This  will  sometimes 
overcome  the  coma  for  a  time,  if  not  severe.  Hypodermoclysis,  or  intra- 
venous injection  with  3  per  cent,  bicarbonate  of  soda  solution  is  also 
recommended  for  the  same  purpose.  The  latter  must  be  specially  pre- 
pared, as  it  cannot  be  sterilized  without  undergoing  chemical  changes. 
(See  p.  232.) 

There  is  nothing  gained  by  keeping  the  children  in  bed,  Joslin's'^ 
experience  in  59  cases  of  the  disease  in  early  life  was  distinctly  in  favor 
of  allowing  them  to  be  about  and  to  exercise  freely.  If  lack  of  strength 
renders  rest  in  bed  necessary  massage  should  be  employed. 


CHAPTER  IX 
DIABETES  INSIPIDUS 


Increased  secretion  of  urine,  temporary  or  of  a  more  chronic  nature, 
is  of  common  occurrence,  and  is  due  to  various  causes.  This  polyuria 
is  referred  to  briefly  later.  (See  Vol.  II,  p.  104.)  Such  cases  are  to  be 
distinguished  from  diabetes  insipidus,  in  which  there  is  a  lasting  excessive 
secretion  of  urine  with  great  thirst.  This  condition  is  not  connnon  at 
any  time  of  life.  It  was  first  clearly  distinguished  fioni  diabetes  mel- 
litus  by  Willis. 3 

Etiology. — Age  exerts  no  noteworthy  predisposing  intluence.  Of 
77  cases  of  all  ages  collected  by  Roberts,'*  22  (31.4  per  cent.)  were  under 

I  Berl.  kliii.  Wochenschr.,  1903,  XL,  817. 
'  Loc.  cit.,  402. 

'  I'harmaceut.  ration.,  1674,  Sec.  IV,  Cap.  III.  Ref.  Sonator,  in  Zienissen's 
Hand.  d.  spec.  Path.  u.  Thcrap.,  1876,  XIII,  2.  254. 

*  Urinary  and  Renal  Diseases,  3d  Amer.  Eu.,  1879,  198. 

41 


642  THE  DISEASES  OF  CHILDREN  i 

10  years  of  age,  and  7  of  these  under  5  years.     In  Strauss's'  series  of  85       ' 
eases,  21  (24.7  per  cent.)  were  less  than  10  years  of  age,  and  9  less  than 
5  years,  and  in  124  cases  analyzed  by  Stoermer,-  19  (15.3  per  cent.) 
were  under  10  years  of  age  and  12  of  these  less  than  5  years.     The  dis-       , 
ease  may  appear  occasionally  to  be  congenital.     In  children  the  influence       ; 
of  sex  is  inconsiderable,  whereas  in  adults  many  more  males  are  affected.       I 
Inheritance  is  probably  the  most  powerful  predisposing  factor,  several 
members  of  a  family  perhaps  being  affected.     Various  nervous  conditions 
in  the  parents  seem  to  predispose  to  the  disease  in  the  offspring.     Trauma 
especially  of  the  back  of  the  head  or  neck  has  been  followed  by  diabetes 
insipidus,  and  this  is  true  also  of  morbid  growths  and  other  diseases  of      \ 
the  brain,  syphilis,  and  acute  infectious  disorders.     There  has  been  ob- 
served, too,  an  undoubted  connection  between  diabetes  insipidus  and 
the  pituitary  body,  and  tumors  or  diseases  of  this  gland  may  be  attended      i 
by  polyuria.     In  the  majority  of  instances,  however,  no  cause  can  be      i 
discovered,  although  the  influence  of  the  pituitary  bodj''  may  still  be      I 
active  although  unproven.     There  are  no   post-mortem  lesions  except 
those  productive  of  the  disease  in  secondary  cases.  ] 

Symptoms.^ — ^The  most  marked  early  symptoms  are  great  thirst  and 
excessive  secretion  of  urine.  The  amount  of  iiuid  imbibed  is  sometimes  I 
remarkable  and  the  daily  secretion  of  urine  may  much  exceed  that  of  ] 
diabetes  mellitus,  reaching  from  5  to  15  quarts  (4732  to  14195)  or  occa-  i 
sionallymore.  Itispale,  with  a  specific  gravity  of  from  about  1001  to  1005.  i 
There  is  no  sugar  or  albumin  present,  but  in  some  cases  inosite  has  ! 
been  found.  The  total  solids  excreted  are  usually  normal,  sometimes  in-  j 
creased.  Most  patients  pass  more  urine  during  the  night  than  during  j 
the  day,  and  nocturnal  enuresis  is  common.  The  skin  is  pale  and  dry  i 
with  little  or  no  perspiration;  the  temperature  is  sometimes  subnormal;  ' 
the  blood  exhibits  nothing  characteristic;  the  appetite  is  variable.  The 
general  health  is  often  but  little  affected.  In  many  cases,  however, 
there  is  more  or  less  emaciation  and  malnutrition,  and  bodily  and,  less  i 
often,  mental  development  may  be  retarded  and  a  degree  of  infantilism  i 
result.  Nervous  symptoms  may  be  present,  among  them  neuralgias  of  , 
various  kinds,  restlessness,  vasomotor  disorders,  and  anorexia  or  exces-  i 
sive  appetite. 

Course  and  Prognosis.^ — The  course  of  the  disease  is  of  an  essentially 
chronic  nature      Unless  terminated  by  some  intercurrent  disorder  it  may 
last  for  years; — sometimes  from  infancy  to  adult  life.     In  other  cases      , 
emaciation  and  debility   progress  and  death  ensues  from  this  cause.      ! 
Recover}^,  or,  in  other  instances,  tolerance  may  be  finally  established,  but      i 
absolute  recovery  in  well-established  cases  is  rare. 

Diagnosis. — This   rests  upon   the   persistent  polyuria  and   thirst. 
After  infectious  fevers  there  is  often  a  brief  transitory  polyuria,  which 
lasts  a  few  days  or  even  weeks,  and  a  similar  condition  may  be  associated 
with  hysterical  or  other  nervous  symptoms.     Chronic  interstitial  neph-      i 
ritis  produces  polyuria  but  not  to  so  great  a  degree.     It  exhibits  albu-      j 
minuria  and  casts,  with  diminution  in  the  excretion  of  solids,  and  is      i 
attended  by  other  characteristic  symptoms.  ! 

Treatment.- — The  principal  treatment  consists  in  a  careful  and  ; 
gradual  restriction  of  the  amount  of  fluid  allowed,  not,  however,  to  the  ' 
extent  of  producing  decided  discomfort.     The  clothing  should  be  warm, 

1  Dissert.  Tubingen,  1870.  Ref.  D.  Gerhardt,  Nothnagel  Spec.  Path.  u.  Therap.,  - 
VII,  1. 

2  Dissert.  Kiel,  1892.     Ref.  D.  Gerhardt,  loc.  cit.  j 


PELLAGRA  643 

abundance  of  fresh  air  given,  and  the  diet  of  the  most  sustaining  nature. 
Very  many  drugs  have  been  tried,  none  of  them  proving  satisfactory, 
among  those  most  in  vogue  being  ergot,  antipyrine,  arsenic,  belladonna 
and  opium.  It  is  doubtful  whether  the  meager  hope  of  benefit  from  any  of 
these  counterbalances  the  harmful  secondary'  effects  which  the}-  maj-  pro- 
duce. That  the  disease  may  sometimes  be  associated  with  syphilis 
renders  antisyphilitic  treatment  advisable  in  cases  giving  a  positive 
Wassermann  reaction.  More  recently  pituitrin  has  been  regarded  as 
a  specific  for  the  affection.  Galvanization  of  the  spinal  cord  is  claimed 
to  have  given  good  results. 


CHAPTER  X 
PELLAGRA 


The  nature  of  pellagra  (velle — agra,  rough  skin)  is  still  uncertain.  Long 
attributed  almost  universally  to  a  food-intoxication,  the  opinion  gradu- 
ally spread  that  it  was  an  infectious  disease,  although  satisfactory  proof  of 
this  had  not  been  supplied.  More  recently  the  view  has  developed  that 
it  is  a  "deficiancy"  disorder  due  to  an  absence  of  certain  necessary  sub- 
stances from  the  diet.  It  was  first  recognized  as  a  morbid  entity  by 
Gasper  Casal  in  Spain ^  in  1735,  although  it  had  previously  been  known 
under  various  popular  names;  among  them  that  of  "Mai  de  la  Rosa." 
For  many  years  it  has  been  of  frequent  occurrence  in  Italy,  Roumania, 
Austria  and  some  other  southern  countries  of  Europe,  as  well  as  in  Egypt 
and  India.  Some  cases  have  been  reported  in  England  and  Scotland. 
It  had  been  observed  from  time  to  time  in  the  United  States  for  a  good 
many  years,  a  case  having  been  reported  by  Babcock^  occurring  as 
long  ago  as  1834,  and  one  by  Gray^  in  1864.  Since  1906  it  has  been  rec- 
ognized with  alarmingly  increasing  frequency.  It  was  estimated  by 
Lavinder*  that  over  30,000  cases  had  occurred  in  this  country,  chiefly 
in  the  Southern  States;  yet  nearly  every  State  of  the  Union  has  suffered 
from  it.  Several  cases  in  Philadelphia,  have  come  under  my  observation 
2  of  them  in  children  who  had  never  been  beyond  the  borders  of  Penn- 
sylvania. The  disease,  or  at  any  rate  the  recognition  of  it,  is  certainly 
extending  with  great  rapidity. 

Etiology. — Pellagra  attacks  all  ages,  although  it  seems  most  common 
in  young  adults.  Studies  of  the  malady  as  it  is  found  in  children  in  the 
United  States  have  been  made  by  Snyder,^  Weston"  and  Rice."  Those 
show  that  it  may  occur  even  as  early  as  2  months  of  life,  and  that  it  is 
rather  frequent  between  the  ages  of  6  and  18  months.  In  323  cases 
studied  personally  by  Grimm, *•  15  per  cent,  were  in  subjects  in  the  first 
15  years  of  life.  It  is  very  probable  that  the  incidence  in  childhood  is 
much  greater  than  this.  Females  are  oftenest  attacked,  at  least  in 
America,  in  the  proportion  of  about  3:1;  yet  this  relative  difference  does 
not  apply  so  well  to  early  life,  nor  to  adults  in  other  countries.     The 

'  Hist.  Nat.  y.  Med.  de  el  Princip.  dc  Asturias,  1702,  :V27. 

*  Trans.  Nat.  Assoc,  for  the  Studv  of  Pollagra,  1912,  18. 

3  Aiuer.  Jourri.  In.sanitv,  1H()4.  XXI,  22:^. 

'  Trans.  \at.  A.ssoc.  for  the  Study  of  IVllapra.  1012,  23. 

'  Anier.  Journ.  Dis.  Child.,  1912,  IV,  172. 

8  Amor.  Journ.  Dis.  Child.,  1914,  VII,  124. 

'  Transac.  Nut.  A.s.soc.  for  the  Studv  of  IVUaura,  1912,  IVM. 

3  Trans.  Nat.  .Vssoc.  for  the  Study  of  IVlhigra,  1912,  :V.). 


644  THE  DISEASES  OF  CHILDREN 

disease  is  very  much  more  frequent  in  rural  districts,  and  especially  under 
unsanitary  conditions  and  in  warm  climates.  It  makes  its  appearance 
much  oftenest  in  the  spring  and  summer  months.  A  debilitated  state 
of  health  seems  to  predispose  to  its  development.  It  is  not  considered 
comnmnicable,  yet  a  familial  occurrence  is  very  frequently  observed. 
Knight,  1  for  instance,  reported  10  pellagrins  in  one  family,  and  marked 
familial  predisposition  is  not  uncommon  in  Italy. 

The  direct  cause  is  still  unknown.  The  employment  of  corn-meal  as 
a  food  had  long  been  considered  the  chief  etiological  factor,  but  later  this 
theory  was  modified  to  the  belief  that  the  meal  must  be  of  an  inferior 
qualit}'.  Lombroso-  especially  has  championed  the  theory,  advanced 
by  others  before  him,  that  pellagra  depends  upon  the  action  of  a  mould 
infecting  spoiled  corn,  which  produces  a  food  intoxication  in  those  eating 
it.  The  apparent  fact  that  pellagra  occurs  also  in  those  who  have  not 
eaten  corn,  and  in  infants  who  have  been  fed  only  at  the  mother's 
breast,  as  well  as  the  various  experimental  investigations  made,  have  led 
to  serious  doubt  of  the  existence  of  any  etiological  relationship  between 
pellagra  and  corn,  or  mould  growing  in  it.  Alessandrini  and  Scala^ 
maintained  that  the  disease  is  due  to  the  action  of  silicon  in  a  colloidal 
form  present  in  the  drinking  water,  Sambon^  believed  the  disease  to  be 
an  infectious  one,  dependent  upon  a  protozoon  transmitted  by  the  bite 
of  one  or  more  species  of  Simuhum  fly  (black  fly;  sand-fly;  buffalo  gnat). 
Roberts^  maintained  that  it  is  transmitted  by  the  mosquito.  A  careful 
study  of  the  relationship  of  various  insects  to  the  disease  made  by 
Jennings  and  King^  led  to  the  conclusion  that  the  Stomoxys  calcitrans 
(stable  fly)  was  the  probable  carrier  of  the  infection.  That  it  may  be 
due  to  a  virus  or  an  organism  of  very  minute  size  is  indicated  by  the 
experiments  of  Harris^  who  claims  to  have  produced  the  disorder  in  a 
monkey  by  inoculation  with  a  filtrate  from  human  tissue  passed  through 
a  porcelain  filter.  Inoculation  experiments  by  others  have  been  unsuc- 
cessful and  confirmation  is  needed. 

More  recently  the  prevailing  opinion  has  veered  again  to  the  etiolog- 
ical relationship  of  the  food-supply,  and  the  evidence  for  this  is  so  strong 
that  the  disease  may  be  with  reason  placed  provisionally  among  the 
nutritional  disorders.  Goldberger^  concluded  as  a  result  of  dietetic  ex- 
periments that  the  cause  is  a  lack  of  something  in  the  food.  This  may  be 
a  deficiency  of  protein  combined  with  an  excess  of  carbohydrate,  since 
the  introduction  of  fresh  animal  and  vegetable  protein  into  the  diet  will 
effect  a  cure.  In  209  cases  in  children  in  two  orphanages,  172,  seen  a 
year  later  had,  with  one  exception,  under  a  change  in  the  diet,  failed  to 
exhibit  any  return  of  symptoms.  Wood's^  conclusions,  based  upon  his 
experiments  with  corn  supported  the  view  expressed  by  others  that  the 
cause  is  a  deficiency  in  the  vitamins. 

Pathological  Anatomy. — The  lesions  are  subject  to  much  variation 
and  are  uncharacteristic.  Those  of  the  skin  are  at  first  erythema;  but 
finally  those  characteristic  of  normal  old  age,  such  as  atrophy,  pigmenta- 

1  Journ.  Amer.  Med.  Assoc,  1912,  LVIII,  1940. 

^  Trattato  profilattico  e  clinico  della  pellagra,  1892.     German  by  Kurella  1898. 

^  Contributo  nuovo  alia  etiologia  e  patogenesi  della  pellagra,  1914. 

*  Journ.  Tropical  Med.  and  Hyg.,  1910,  XIII,  271. 

6  Amer.  .Journ.  Med.  Sci.,  1913,  CXLVI,  233. 

«  Amer.  .Journ.  Med.  Sci.,  1913,  CXLVI,  411. 

'  .'ourn.  Amer.  Med.  Assoc.,  1913,  LX,  1948. 

s  Journ.  Amer.  Med.  Assoc,  1916,  LXVI,  471. 

9  Journ.  Amer.  Med.  Assoc,  1916,  LXVI,  1447. 


PELLAGRA 


64i 


tion  and  sclerotic  alterations.  Pigmentation  maj-  take  place  in  the  viscera ; 
the  kidney  may  be  cirrhotic;  the  liver  and  spleen  are  often  smaller  than 
normal;  brown  atrophy  of  the  cardiac  muscle  is  common;  the  fat  of  the 
body  is  much  diminished  and  the  muscles  atrophied ;  the  fragility  of  the 
bones  is  increased.  There  maj'  be  evidences  of  chronic  inflammatory 
changes  in  the  brain,  meninges  and  spinal  cord.  The  chief  lesions  in 
the  nervous  system  appear  to  be  in  the  spinal  cord,  especially  the  pyra- 
midal tracts,  but  the  posterior  columns  are  also  involved.  It  is  question- 
able, however,  whether  many  of  the  post-mortem  alterations  are  directly 
connected  with  the  disease  itself,  or  are  not  rather  those  which  would  be 
seen  in  senility  or  in  chronic  cachectic  states  from  any  cause. 

Symptoms  and  Course. — The  method  of  onset  and  the  symptoms 
seen  are  subject  to  considerable  variation.  The  latter  can  be  divided 
into  cutaneous;  digestive;  and  nervous.     Any  one  of  these  groups  may 


Fig.  224. — Pellagra. 
Case  in  a  girl  of  9  years,  in  the  Children's  Medical  Ward  of  the  Hospital  of  the  University 
of  Pennsylvania,  under  the  care  of  Dr.  M.  B.  Hartzell.     The  child  had  never  been  outside 
of  Pennsylvania.     Courtesy  of  Dr.  Hartzell  and  of  the  J.  B.  Lippincott  Co. 


appear  first  or  be  most  prominent.  The  cutaneous  are  the  character- 
istic manifestations.  These  may  come  on  very  insidiously  or  suddenly, 
the  first  change  being  a  symmetrically  developed  erythema  on  the  e.xposed 
parts  of  the  body,  such  as  the  backs  of  the  hands,  the  face  and  the  neck; 
or  in  other  cases,  if  the  patient  does  not  wear  shoes,  also  on  the  feet  and 
legs  up  to  the  knees.  It  resembles  sunburn  and  in  mild  ca.sos.  and  esjie- 
cially  in  young  children,  may  easily  escape  recognition.  In  typical  in- 
stances the  erythema  becomes  darker  red  and  livid,  and  is  followed  in  al)out 
2  weeks  or  more  by  drying,  scaling  {dry-type)  and  pigmentation  of 
the  epidermis  (Fig.  224).  At  the  wrists  or  on  the  forearms  it  is  sharply 
demarcated  from  the  healthy  skin  above  it,  giving  sometimes  the 
appearance  of  a  glove  ("pellagrous  glove");  or  this  may  be  seen  on  the 
foot  and  leg  also  ("pellagrous  boot"),  or  around  the  neck  ("Cdsal's 
necklace");  in  fact  wherever  the  covered  joins  the  exposed  skin.  In 
some  cases  vesicles  and  bulhe  develop  {wd-type),  or  there  may  be  sup- 
puration beneath  the  scaly,  crusted  epidermis.  After  a  few  months  in 
the  milder  cases  recovery  occurs  and  the  skin  resumes  its  normal 
appearance. 

With  or  preceding  the  cutaneous  symptoms  there  are  digestive  dis- 
turbances, generally  most  marked  in  children  under  4  years  of  age.     Of 


646  THE  DISEASES  OF  CHILDREN 

these  severe  diarrhea,  often  dysenteric,  is  one  of  the  most  prominent  and 
troublesome,  and  frequently  the  first  to  appear.  Stomatitis,  with  red- 
ness of  the  tongue  and  gums,  is  often  present  and  is  characteristic;  saliva- 
tion may  occur,  and  vomiting  is  common ;  or  there  msiy  be  loss  of  appetite 
and  abdominal  pain.  Nervous  and  general  symptoms,  too,  may  develop 
at  an}^  period.  The  child  may  be  very  little  ill,  or  there  may  be  malaise, 
loss  of  flesh,  vertigo,  depression,  insomnia,  headache,  and  cramps  in 
various  parts  of  the  body.  Occasionally  severer  nervous  symptoms  indi- 
cating lesions  of  the  cord  may  be  among  the  earliest  manifestations,  here 
especially  being  paresthesia  and,  very  often,  exaggerated  reflexes.  The 
examination  of  the  blood  reveals  nothing  characteristic.  There  may  be 
secondary  anemia,  but  no  leucocytosis  or  eosinophilia. 

This  is  perhaps  the  history  of  the  first  attack.  Entire  recovery  may 
seem  to  have  taken  place;  but  in  the  course  of  the  year,  sometimes  in  the 
autumn  but  much  oftenest  by  the  next  spring,  a  second  attack  occurs, 
and  this  recurrence  may  be  repeated  during  several  years  as  spring  comes 
on,  the  same  symptoms  developing  but  of  greater  severity  and  of  longer 
continuance.  Sometimes  several  years  may  pass  by  without  an  attack. 
Other  regions  of  the  body  may  become  involved,  as  the  entire  forearms, 
the  shoulders  and  the  genital  region;  and  very  occasionally  the  eruption  is 
universal.  The  skin  in  these  later  attacks  is  often  not  so  vividly  red  as 
in  the  first,  but  is  more  deeply  infiltrated  and  undergoes  fissuring  and 
finally  atrophy,  assuming  a  permanently  pigmented,  parchment-like 
character,  with  exacerbations  of  the  erythema  appearing  in  the  spring- 
time. The  nervous  symptoms  are  more  marked  in  the  later  attacks, 
consisting  then  of  very  great  lassitude,  diffuse  pains,  paralytic  or  con- 
vulsive conditions,  mental  depression  or  insanity.  Mental  disturbances, 
however,  although  frequent  in  advanced  cases  in  adults,  are  compara- 
tively uncommon  in  children;  except  for  a  degree  of  dullness  or  irritability. 
In  the  final  stage  there  is  profound  prostration,  with  great  emaciation 
and  the  development  of  the  typhoid  state. 

Prognosis. — On  the  whole  this  is  very  unfavorable.  The  death- 
rate  in  America  according  to  Lavinder^  equalled  37  per  cent,  in  the  15,870 
cases  collected  by  him.  Recovery  in  fully  developed  cases  is  very  unusual. 
Death  took  place  in  the  1st  year  of  the  disease  in  12  out  of  55  cases  col- 
lected by  Tucker. 2  Although  apparent  recover}^  often  occurs  readily, 
recurrence  of  the  symptoms  is  very  liable  to  take  place;  and  after  per- 
haps many  years  the  patient  dies.  Sambon^  reported  a  case  in  a  woman 
of  88  years  who  had  had  the  disease  since  she  was  17  years  of  age.  Such 
a  duration  as  this  is,  however,  unusual.  Severe  cases  may  be  fatal  in 
2  to  3  years,  but  generally  the  disorder  lasts  a  longer  time.  There  is 
reason  to  believe  that,  although  pellagra  is  more  rapidly  fatal  in  infancy, 
in  children  from  the  age  of  4  to  10  years  the  course  is  milder  and  recovery 
may  take  place  under  suitable  treatment.  If  the  deficiency-theory  is 
correct,  there  is  reason  to  hope  that  the  prognosis  in  the  future  may  be 
greatly  better  under  proper  dietetic  management. 

Diagnosis. — The  positive  diagnosis  can  be  made  only  upon  the 
development  of  the  characteristic  cutaneous  eruption,  alone  or  in  combi- 
nation with  the  digestive  and  nervous  disturbances  described.  In  re- 
gions where  pellagra  is  endemic,  at  least  a  provisional  diagnosis  may  be 
made  before  cutaneous  symptoms  are  seen,  based  upon  the  combination 

1  Loc.  cit. 

2  journ.  Amer.  Med.  Assoc,  1911,  LVI,  246. 

3  Trans.  Nat.  Assoc,  for  the  Study  of  Pellagra,  1912,  87. 


PELLAGRA  647 

of  redness  of  the  tongue,  diarrhea,  lassitude,  headache,  paresthesia  and 
other  nervous  sjanptoms. 

Treatment. — Infants  with  pellagrous  mothers  should  not  nurse 
from  them.  This  is  not  because  the  malady  is  transmissible,  but  be- 
cause the  milk  is  generally  inferior  in  quality,  and  infants  continued  at 
the  breast  develop  intestinal  disorders  and  an  atrophic  state.  In  cases 
of  an}^  age  the  most  favorable  hygienic  surroundings  should  be  chosen, 
including,  if  possible,  change  of  environment,  especially  to  a  cooler  cli- 
mate. Hydrotherapy  has  been  very  valuable.  The  diet,  too,  should  be 
made  abundant  and  nourishing,  and  changed  in  some  way  from  that 
which  has  been  employed;  especial  care  being  taken  to  diminish  the 
amount  of  carbohydrate  and  increase  that  of  animal  or  vegetable  protein. 
Tonic  remedies  to  improve  the  general  health  may  be  needed,  including 
iron  and  arsenic  either  by  the  mouth  or  hypodermically;  and  a  search 
for  and  removal  of  associated  intestinal  parasites  is  of  importance.  This 
treatment  is  to  be  followed  not  only  in  the  developed  disease,  but  as  a 
prophylactic  measure,  in  view  of  the  decided  predisposing  influence  which 
poverty  and  ill  health  exert.  For  the  local  treatment  exposure  to  sun- 
shine should  be  avoided,  as  this  tends  to  produce  or  increase  the  eruption, 
and  soothing  applications  should  be  used,  such  as  are  indicated  in  various 
forms  of  ervthema. 


SECTION  IV 

DISEASES  OF  THE  DIGESTIVE  SYSTEM 


CHAPTER  I 

DISEASES  OF  THE  MOUTH,  LIPS,  JAWS,  TONGUE 
AND  SALIVARY  GLANDS 

DISEASES  AND  MALFORMATIONS  OF  THE  JAWS 

The  failure  of  union  of  the  two  sides  of  the  upper  jaw  is  described 
under  cleft  palate  (p.  670) ;  and  the  narrowing  caused  by  the  presence 
of  adenoids  is  referred  to  elsewhere  (p.  688).  Prognathism  of  the  upper 
jaw  is  not  infrequent.  It  may  be  a  fault  of  development,  or  may  some- 
times be  produced  by  thumb-sucking  (Vol.  II,  p.  284).  As  a  result  the 
upper  teeth  slant  forward  beyond  the  lower.  Prognathism  of  the  lower 
jaw  is  also  encountered.  Sometimes  the  lower  jaw  is  abnormally  small 
(micrognathia),  the  teeth  failing  to  come  into  position  below  the  upper 
ones  when  the  mouth  is  closed.  Very  occasionally  exostoses  are  en- 
countered; or  odontomata  from  irregularity  in  the  development  of  one  or 
more  teeth  of  the  second  set  within  the  body  of  the  jaws.  Malignant 
new  growths  connected  with  the  jaw  are  of  very  great  infrequency  in 
early  life,  the  most  common  being  sarcoma.  Tumors  arising  at  the 
junction  of  the  gums  with  the  jaw  {epulis)  are  occasionally  seen.     The 

nature  of  these  varies.  Generally  the 
growth  is  a  simple  granuloma  connected 
with  a  diseased  tooth;  but  even  if  sarcomat- 
ous, their  removal  is  generally  not  followed 
by  any  return.  Maxillary  cysts  of  con- 
genital origin  may  be  seen.  Necrosis  of  a 
portion  of  the  jaw  may  follow  alveolar 
abscess,  ulcerative  stomatitis,  or  noma;  and 
in  cases  of  the  last-mentioned  disorder  in 
which  life  is  not  lost,  very  great  deformity 
may  remain.  Ankylosis  of  the  jaw  may 
result  from  noma  or  from  traumatism.  A 
chronic  ostitis  may  be  produced  by 
tuberculosis  or  sj^philis. 

DISEASES  OF  THE  LIPS 

Harelip. — This  very  common  de- 
formity is  caused  by  the  failure  of  the 
frontonasal  plate  to  unite  with  the  lateral 
process  on  one  side,  thus  producing  a 
fissure  beneath  the  nostril  (single  hare  lip).  When  occurring  on  both 
sides  double  harelip  results  (Fig.  225).  The  fissure  varies  in  degree 
from  a  slight  notching  to  a  complete  cleft  passing  into  the  nostril.  In 
the  latter  event,  particularly  if  on  both  sides,  cleft  palate  also  is 
commonly  present. 

The  fissure  may  be  great  enough  to  interfere  with  nursing,  with 
consequent  inanition  from  lack  of  nourishment.     Apart  from  great  care 

648 


Fig.  225. — Harelip  on  Left  Side. 

(Willard,  Surgery  of  Childhood,  38, 

Fio.  22.) 


DISEASES  OF  THE  LIPS 


649 


for  cleanliness  of  the  mouth  the  treatment  is  entirely  surgical.  Operation 
should  be  done  at  from  2  to  3  months  of  age  unless  difficulty  in  feeding 
the  child  makes  earher  interference  necessary.  The  infant  should  be  in 
as  good  general  condition  as  possible  at  the  time. 

Erosions  at  the  Angles  of  the  Mouth  (Faule  Ecken;  Perleche). — 
This  condition,  long  known,  but  first  carefuU}^  studied  by  Lemaistre^  in 
1886  and  called  La  Perleche,  is  not  of  very  frequent  occurrence.     The 
French  name  is  derived  from  the  tendency  of  the  patient  to  lick  the  affected 
areas  (pour  lecher). 

Etiology. — It  effects  especially  early  childhood,  being  rarely  seen  in 
adults;  is  favored  by  the  presence  of  a  state  of  debility  and  by  unclean- 
liness;  and  would  even  appear  to  be  contagious,  since  several  members  of 
one  family  may  be  attacked,  or  it  may  occur  epidemically  in  schools. 
A  streptococcus  has  been  described  by  Lemaistre. 


Fig.  226. — Erosions  at  the  Angles  of  the  Mouth. 
(Epstein,  Jahrh.  f.  Kinderheilk.,  1900,  LI,  317.) 


Symptoms. — The  lesions  consist  of  small,  fissure-like  ulcers  arranged 
radially  at  the  labial  angle,  generall}^  at  both  sides.  The  skin  is  red  and 
swollen,  and  under  the  influence  of  the  moistening  by  the  constant  applica- 
tion of  the  tongue  a  grayish  ulcer  of  larger  size  may  develop  (Fig.  226). 
The  lesions  arc  painful,  but  do  not  affect  the  child  in  other  respects. 
The  course  is  favorable  and  recovery  takes  place  in  from  2  to  4  weeks 
under  treatment,  leaving  no  scars  in  the  majority  of  instances;  but  with- 
out treatment  the  course  may  be  prolonged  and  may  become  chronic. 
Except  in  severe  cases  there  is  no  lymi)hatic  involvement. 

Diagnosis. — ^This  is  a  matter  of  importance  since  the  lesions  ])ear  a 
resemblance  to  the  placjues  of  syphilis.  Thej'  differ  in  that  the  fissures 
never  extend  into  the  mouth  nor  deeply  into  the  tissues;  are  without 
induration  at  the  base;  and  are  not  strictly  limited  to  the  conunissures. 

Treatment.  —  In  the  way  of  pi-ophylaxis  care  merely  nuist  be  taken  for 
cleanliness  of  t  \\v  mouth  and  against  jjossible  infection  from  other  children. 
The  fissures  should  be  touched  with  a  solution  of  nitrate  of  silver,  10  per 

1  Etmlc  sur  I'iiir  de  la  villc;  Limoges,  de  la  pcrlC-chc,  du  streptococcus  plicatilis. 
Ref.,  Coinby,  Trait6  des  mal.  de  I'cnf.,  1904,  II,  13. 


650  THE  DISEASES  OF  CHILDREN 

cent.,  a  crj'stal  of  sulphate  of  copper,  tincture  of  iodine,  or  burnt  alum,  and 
then  covered  with  a  healing  ointment,  as  of  zinc  or  bismuth,  or  have  ap- 
plied compound  tincture  of  benzoin,  ointment  of  yellow  oxide  of  mer- 
cury, or  25  per  cent,  ichthyol. 

Other  Affections  of  the  Lips,  such  as  syphilitic  lesions,  herpes,  eczema, 
and  the  like,  are  discussed  in  the  sections  deal  ng  w'.th  these. 

ANOMALIES  OF  DENTITION 

Natal  Teeth  {Dentitio  prcecox). — Very  rarely  infants  are  born  with 
one  or  more  teeth.  Ballentyne^  was  able  to  collect  but  70  reported  cases, 
and  states  that  in  the  Paris  Maternity  from  1858  to  1868  the  anomaly 
occurred  but  3  times  in  17,578  births.  The  tendency  is  in  rare  instances 
hereditary.  These  natal  teeth  are  nearly  always  the  central  incisors 
in  the  lower  jaw.  The  tooth  is  usually  poorly  developed,  and  often  so 
loosely  attached  that  extraction  is  necessary.  If  this  is  not  the  case 
it  should  be  allowed  to  remain  unless  it  renders  nursing  too  painful  to  be 
tolerated.  Natal  teeth  may  sometimes  be  supernumerary  and  then  will 
be  replaced  later  by  the  teeth  of  the  first  dentition. 

Early  Dentition.^ — ^Dentition  may  occur  remarkably  early,  and 
the  age  of  3  months  may  see  the  first  incisors  appearing.  This  is  an 
occasional  characteristic  of  hereditary  syphilis,  but  is  not  a  proof  of  the 
existence  of  this  disease. 

Delayed  Dentition.^ — Much  more  frequent  than  prematurity  of 
dentition  is  that  of  delay.  Within  normal  limits  the  first  teeth  may  not 
appear  until  the  age  of  a  year,  but  a  period  longer  than  this,  or  even  not 
exceeding  it,  is  a  strong  indication  of  the  presence  of  rickets,  which 
is  the  most  frequent  cause.  Cretinism,  too,  is  attended  by  delay  in  the 
first  appearance  of  teeth. 

Irregularities  of  Dentition. ^ — Disturbed  sequence  in  the  eruption 
of  the  teeth  seems  to  have  but  little  significance.  The  appearance  of  the 
upper  incisors  before  the  lower  has  been  claimed  (Jacobi),^  to  be  an  attend- 
ant upon  idiocy  with  premature  ossification  of  the  cranium.  It  certainly, 
however,  occurs  in  many  normal  infants.  Rachitis  is  a  not  infrequent 
cause  of  a  disarrangement  of  the  sequence.  Irregularities  in  the  shape  and 
character  of  the  teeth  are  seen  especially  in  the  disposition  to  caries  follow- 
ing severe  constitutional  diseases.  This  is  especially  true  of  rickets  and  of 
tuberculosis  and  the  so-called  scrofulosis.  Furrowing  and  erosions  of  the 
teeth,  especially  those  of  the  permanent  set,  may  be  due  to  defective 
formation  of  the  enamel,  often  dating  from  the  occurrence  of  stomatitis 
or  of  some  constitutional  illness  in  early  childhood;  or  the  condition  may 
be  hereditary.  The  notching  and  the  development  of  a  peg-shaped  form 
of  the  permanent  incisors  in  inherited  syphilis  is  also  to  be  noted.  (See 
Syphilis,  p.  576.)  Other  irregularities  are  sometimes  seen,  such  as  that  of 
size,  certain  teeth  being  abnormally  small,  or  some  abnormally  large. 
The  number  of  the  teeth  is  sometimes  abnormal,  one  or  more  teeth  being 
wanting,  or  occasionally  the  number  being  greater  than  normal.  This 
is  more  often  seen  in  the  permanent  set  than  in  the  temporary.  Failure 
of  the  temporary  teeth  to  fall  out  at  the  proper  time  is  hable  to  occasion 
malposition  of  those  of  the  second  set.  I  have  exceptionally  seen  so 
many  of  the  first  set  remaining  in  position  that  the  child  actually  appeared 
to  have  two  rows  of  teeth  in  each  jaw.  Excessive  thumb-sucking  some- 
times forces  the  incisors  of  the  lower  jaw  inward  and  those  of  the  upper 

1  Edinb.  Med.  Journ.,  1896,  II,  102.5. 

2  Intestinal  Diseases  of  Infancy,  1887,  102. 


ANOMALIES  OF  DENTITION  651 

jaw  outward  (see  Thumb-sucking,  Vol.  II,  p.  282),  as  may  also  the  con- 
stant sucking  at  a  rubber  "comforter."  Lip-sucking,  too,  may  cause 
depression  of  the  lower  incisors. 

Difficult  Dentition. — Formerly  it  was  the  general  practice  of 
physicians  to  attribute  to  "teething"  ailments  of  many  sorts  which  are 
now  generally  admitted  to  have  no  actual  connection  with  it.  Unfor- 
tunately the  custom  is  still  widespread  among  the  laity,  and  even  to  too 
great  an  extent  in  the  medical  profession  as  well.  Opposed  to  this  view  is 
the  more  modern  one  that  teething  is  a  purely  phj'siological  process  and 
never  produces  unpleasant  symptoms.  The  truth  probably  lies  some- 
where between  these  extremes,  although,  with  many  others,  I  am  con- 
vinced that  the  role  played  by  teething  in  the  production  of  symptoms  is 
a  very  small  one,  and  that,  as  a  rule,  dentition  produces  only  teeth.  The 
error  lies  largeh'  in  assuming  that  the  redness  of  the  gum  over  a  tooth 
about  to  appear  is  an  indication  of  trouble  produced  by  the  tooth.  The 
question  hinges  upon  what  is  to  be  called  the  eruption  of  a  tooth.  As  a 
matter  of  fact  there  is  scarcely  a  time  in  the  first  2  years  of  life  when  a 
tooth  is  not  either  pushing  through  the  gums  or,  more  deeply  situated, 
through  the  alveolar  process.  If  pain  and  other  disturbances  are  caused 
by  the  tooth  they  should  rather  occur  during  the  more  difficult  process — 
the  advance  of  the  tooth  through  the  resistant  bony  structure — for  the 
thin  layer  of  the  gum  overlying  a  tooth  which  is  nearly  erupted  is,  as  is 
well  known,  comparatively  insensitive.  Lancing  of  the  gum  often 
relieves  a  catarrhal  stomatitis  and  the  accompanying  local  and  nervous 
symptoms;  but  it  is  the  stomatitis,  not  the  presence  of  the  tooth,  which 
is  causing  the  disturbance  in  the  majority  of  cases,  and  which  is  relieved  by 
the  operation.  This  is  shown  by  the  fact  that  the  employment  of  other 
remedies  for  the  relief  of  the  stomatitis  is  often  promptly  followed  by 
disappearance  of  the  symptoms  which  had  been  attributed  to  teething. 

Nevertheless  there  are  sometimes  instances  seen  in  particularly 
susceptible  children  where  the  close  approach  of  a  tooth  to  the  gum  and 
the  pressure  upon  this,  without  any  discoverable  stomatitis,  produces 
symptoms  promptly  relieved  by  lancing.  I  have  occasionallj'  seen  such 
instances,  but  I  have  oftener  failed  to  see  any  benefit  following  lancing. 
Among  these  symptoms  may  be  mentioned  moderate  fever,  restlessness, 
disturbed  sleep,  fretfulness,  loss  of  appetite,  diarrhea,  and  a  constant 
tendency  to  put  the  hands  into  the  mouth.  Convulsions  may  very 
rarely  occur,  but  I  have  never  seen  an  instance  of  this  which  could  be 
unequivocally  attributed  to  teething.  As  all  the  symptoms  involved  may 
be  due  to  a  catarrhal  stomatitis,  associated  with  gastrointestinal  dis- 
orders, or  may  be  dependent  upon  more  remote  causes,  the  necessity  of 
most  careful  examination  of  tlu;  whole  l)ody  becomes  evident.  Lancing 
of  the  gums  should  be  the  last  thought  entertained  ])y  the  physician;  not 
the  first,  as  is  too  often  the  case.  Moreover,  gum-lancing,  if  not  followcil 
by  a  prompt  eruption  of  the  tooth,  may  readily  pixxhice  a  cicatrix  which 
would  increase  tlie  supj)ose(l  difficulty  in  the  eruption  which  the  proceilurc 
was  intended  to  alleviate. 

Alveolar  Abscess  {(jum-boil). — This  is  a  common  affection,  es- 
pecially in  those  whose  teeth  have  been  neglected.  Following  a  peri- 
cementitis an  abscess  develops  about  the  root  of  a  tooth.  Pain  and 
swelling  result,  sometimes  with  fever.  The  whole  side  of  the  face  may  be 
much  swollen.  The  pus  usually  discharges  itself  into  the  mouth,  but 
occasionally  externally  through  the  cheek  or  into  tlie  antrum.  'I'reat- 
ment  consists  in  the  employment  of  hot  applications  within  the  mouth, 
and  the  opening  of  the  abscess  as  soon  as  possible. 


652  THE  DISEASES  OF  CHILDREN 

Caries  of  the  Teeth. — This  condition  should  be  mentioned  especially 
on  account  of  its  deleterious  influence  upon  the  system  in  general.  It  is 
of  extremely  common  occurrence  even  in  early  childhood.  Caries  results 
chiefl}^  from  lack  of  care  of  the  teeth.  There  is  also  a  predisposition 
to  it  in  children  suffering  from  depressed  health  from  any  source,  and  it 
is  particularly  frequent  in  rickets.  An  improper  diet  is  also  an  active 
factor,  especially  the  frequent  eating  of  sugar  in  any  form,  since  the 
organisms  producing  the  disorder  thrive  in  a  sugar-medium.  Apart  from 
the  direct  effect  of  the  caries,  such  as  toothache,  imperfect  mastication, 
foul  breath,  alveolar  abscess,  forms  of  stomatitis,  and  the  like,  absorption 
may  readily  take  place  through  the  resulting  gingivitis.  Tuberculosis 
of  the  glands  below  the  jaw  and  finally  even  of  more  distant  parts  of  the 
body  may  occur;  and  it  is  likely  that  anemia,  continued  fever,  and  acute 
and  chronic  rheumatic  conditions  may  be  brought  about  in  the  same  way. 
In  any  event  it  is  certain  that  the  treatment  of  the  inflammation  of  the 
gums  associated  with  caries  appears  to  be  an  essential  in  obtaining  im- 
provement of  the  general  condition  in  many  instances.  It  is  probable, 
too,  that  the  irritation  produced  by  carious  teeth  is  responsible  for  many 
nervous  conditions,  such  as  habit-spasm  in  which  the  face  is  involved, 
as  well  as  headache.  The  importance  of  effort  for  the  prevention  of 
dental  caries  is  evident  and  of  prompt  treatment  if  already  present;  and 
this  applies  to  the  first  set  of  teeth  as  well  as  the  later  ones.  Many 
mothers  regard  it  as  a  matter  of  indifference  whether  or  not  the  primary 
teeth  decay,  and  fail  to  consult  a  dentist  regarding  this.  Not  only  are 
the  results  mentioned  liable  to  happen,  but  it  is  of  frequent  occurrence 
that  the  6-}'ear-old  molars,  erupting  as  the}'  do  without  the  displacement 
of  any  of  the  primary  teeth,  come  in  and  decay  without  this  being 
discovered. 

CATARRHAL  STOMATITIS 

Etiology. — This  disorder  is  not  only  a  very  common  affection,  but 
is  an  attendant  upon  various  other  diseases.  It  is  oftenest  seen  in  early 
childhood  and  especially  in  infancy.  The  period  of  life  at  which  it  is 
most  likely  to  occur  is  that  for  the  eruption  of  the  temporary  teeth. 
This  is  not  evidence,  however,  that  dentition  is  in  any  way  causative  of 
it.  (See  p.  651.)  Traumatism  of  various  sorts  is  active  in  its  produc- 
tion. Here  may  be  mentioned  rough  washing  of  the  mouth  by  the  nurse, 
which  is  a  very  frequent  agent,  and  the  action  of  hot  or  chemically 
irritating  substances.  A  common  etiological  factor  is  lack  of  cleanli- 
ness, the  result  either  of  neglect  or  of  the  introduction  of  unclean  ob- 
jects into  the  mouth,  and  the  consequent  irritation  through  bacteriolog- 
ical action  which  follows.  Diseases  of  the  gastroenteric  tract  are  very 
commonly  attended  by  catarrhal  stomatitis,  as  are  many  of  the  acute 
infectious  disorders,  especially  measles,  diphtheria  and  scarlet  fever;  and 
other  varieties  of  stomatitis  are  constantly  accompanied  by  inflammation 
of  the  catarrhal  form. 

Symptoms. — The  mucous  membrane  of  the  mouth  becomes  red, 
swollen,  hot  and  tender.  The  change  is  seen  especially  on  the  gums  and 
the  tongue,  but  frequently  also  on  the  lining  of  the  lips,  cheeks  and  palate. 
Slight  bleeding  may  occur.  The  central  portion  of  the  dorsum  of  the 
tongue  is  usually  coated,  while  the  tip  and  edges  exhibit  swollen  and  red 
filiform  papillae.  Not  infrequenth^  the  whole  of  the  dorsum  is  red.  The 
swelling  is  especially  marked  on  the  mucous  membrane  about  the  teeth. 
The  tongue  and  hps  may  be  fissured.     Salivation  is  decided  and  often 


APHTHOUS  STOMATITIS  653 

SO  excessive,  particularly  in  nurslings,  that  the  secretion  overflows  the 
lips,  irritates  the  surrounding  skin  and  moistens  the  clothing.  That  the 
inflammation  is  painful  is  evidenced  by  the  complaints  of  older  children, 
and  by  the  continued  restlessness,  fretfulness,  crying  and  sleeplessness  of 
infants,  and  their  refusal  to  take  food,  although  clearly  hungry.  An 
attempt  to  nurse  is  promptly  followed  by  dropping  of  the  nipple  ^vath  a 
cry  of  pain.  Moderate  swelling  of  the  lymphatic  glands  below  the  jaw 
may  occur.  The  temperature  is  normal  or  slightly  elevated.  Diarrhea 
and  vomiting  may  occur,  but  rather  as  complications  or  as  causes  than 
as  symptoms  of  the  disease. 

The  course  of  the  disease  is  a  few  days  or  a  week  in  length  in  children 
under  treatment  and  otherwise  healthy.  In  those  debilitated  or  suffering 
from  other  affections  it  may  be  much  longer. 

Treatment. — Food  is  best  given  in  a  cool  form  and  liquid  or  soft. 
If  sucking  is  painful,  feeding  with  a  spoon  can  be  employed.  Should  all 
food  be  refused,  gavage  may  be  used,  but  this  is  rarely  necessary.  Small 
pieces  of  ice  may  be  put  frequently  into  the  mouth.  The  mouth  should 
be  kept  very  clean  through  oft-repeated  washing  with  cold  water;  a  solu- 
tion of  potassium  permanganate  (1  :8000  or  stronger);  or  a  saturated 
solution  of  boric  acid,  to  which  a  little  tincture  of  myrrh  may  well  be 
added  (1  :24).  All  rough  cleansing  processes  must  be  avoided,  and  a 
soft  pledget  of  absorbent  cotton  moistened  with  the  solution  employed. 
Painting  with  a  weak  solution  of  nitrate  of  silver  (1  to  2  per  cent.)  may 
be  used  in  obstinate  cases.     Internal  medication  is  hardly  required. 

APHTHOUS  STOMATITIS 
(Herpetic  Stomatitis,  Maculo-fibrinous  Stomatitis,  Aphthae) 

The  nature  of  this  affection  is  not  well  understood.  The  title  "her- 
petic" has  been  employed  on  the  theory  that  the  lesions  were  the  counter- 
part of  herpes  upon  the  lips;  but  this  relationship,  although  possible,  has 
not  been  proven,  and  the  title  "herpetic  stomatitis"  may  well  designate 
inflammation  of  another  variety.  (See  Simple  Ulceration,  p.  663.) 
"Aphthae"  is  a  title  long  in  vogue  and  formerly  applied  to  a  variety  of 
affections  of  the  mouth. 

Etiology. — Age  has  a  predis])osing  influence,  the  disease  being 
most  common  in  infancy  and  early  childhood,  and  especially  in  the  2d 
year  of  life,  although  not  infrequent  in  adults.  In  587  cases  in  earlj^  life 
studied  by  Monti ^  the  ages  were:  Under  6  months,  10;  in  the  1st  year, 
69;  1  to  2  years,  290;  2  to  3  years,  106;  3  to  4  years,  45;  4  to  14  years.  77. 
The  previous  health  has  no  influence  except  that  the  disease  is  not  infre- 
quently associated  with  disturbances  of  the  digestion.  I'ncleanlincss  of 
the  mouth  appears  to  be  an  important  predisposing  factor.  In  certain 
subjects  there  is  seen  a  decided  tendency  to  frequent  recurrence.  No 
specific  microorganism  has  been  demonstrated,  nor  has  an  infectious 
quality  l)een  certainly  proven,  although  often  believed  to  exist.  It  has 
been  claimed  by  Ollivier-  and  others  that  the  malady  is  identical  with 
the  foot-and-mouth-disease  of  cattle  and  transmitted  from  tiiein.  l)ut  for 
this  view  there  appeai-s  to  b(>  no  sufficicMit  basis. 

Pathological  Anatomy. — Tiie  lesions  consist  of  small  i)at('hes  of 
irregular  siiape,  varying  in  size  from  that  of  a  small  pinhead  to  that  of  a 
split-pea.     Tiiey  are  discrete,  or  occasionally  somewhat  confluent.     The 

'  Honoch's  Festschrift,  1S90,  4(51. 

-  Rev.  mens.  <les  inal.  <U's  I'onf.,  1S<)2,  X.  11. 


654  THE  DISEASES  OF  CHILDREN 

lesion  appears  at  first  as  an  elevation  of  the  epithelium  with  a  red  margin 
and  a  whitish  centre.  It  is  produced  by  cellular  proliferation  and  fibrin- 
ous exudation  beneath  the  epithelium,  surrounded  by  a  zone  of  hyper- 
emia. It  is  very  possible  that  a  vesicle  first  develops  but  is  unrecognized 
on  account  of  the  influence  of  the  moisture  of  the  mouth.  In  about  24- 
hours  the  epithelial  covering  is  lost  and  an  opaque  whitish  or  yellowish 
patch  remains.  This  is  superficial  and  is  level  with  the  surrounding 
mucous  membrane;  that  is  to  say,  it  is  not  an  ulcer  in  a  strict  sense,  but 
an  infiltration;  and  if  effort  be  made  to  remove  the  exudate  a  bleeding 
surface  remains.  The  exudate  is  absorbed  in  a  few  days  without  necrotic 
change  taking  place,  and  new  epithelium  spreads  over  the  erosion  which 
remains. 

Symptoms. — The  principle  symptom  consists  in  the  presence  of 
the  lesions  and  the  local  conditions  produced  by  them.  The  plaques  ap- 
pear in  successive  crops,  their  favorite  seat  being  the  inner  surface  of  the 
lips  and  the  edge  of  the  tongue,  although  any  part  of  the  oral  cavity  may 
be  attacked.  The  process  may  occasionally  extend  to  the  pharynx  and 
tonsils.  The  lesions  may  be  few  in  number  and  are  usually  chiefly  dis- 
crete, but  sometimes  numerous  and  coalesce  into  large,  irregular  patches. 
They  are  painful  and  tender  to  the  touch,  and  the  taking  of  food  is  often 
almost  refused  on  account  of  the  suffering  produced;  the  pain  being  simi- 
lar to  that  present  in  catarrhal  stomatitis,  but  greater.  The  secretion 
of  saliva  is  increased ;  the  tongue  is  coated ;  there  may  be  an  odor  to  the 
breath,  but  not  of  the  offensive  character  present  in  ulcerative  stomatitis. 

The  general  symptoms  consist  of  malaise,  loss  of  appetite,  often 
moderate  fever,  fretfulness  and  disturbed  sleep;  the  degree  of  these  cor- 
responding to  that  of  the  involvement.  The  cervical  lymphatic  glands 
are  sometimes  enlarged  in  severe  cases. 

Complications. — Catarrhal  stomatitis  always  accompanies  the 
process;  herpes  labiahs  is  sometimes  seen;  and  vomiting  and  diarrhea  may 
occur. 

Course  and  Prognosis.^ — In  the  milder  discrete  cases  the  duration 
is  seldom  more  than  a  few  days  or  a  week  and  the  prognosis  is  entirely 
good.  The  confluent  cases  last  somewhat  longer.  If  previous  constitu- 
tional debility  exists  the  duration  may  be  extended  to  2  or  3  weeks  through 
the  persistent  development  of  fresh  crops,  and  the  general  nutrition  may 
be  affected. 

Diagnosis. — As  a  rule  this  is  unattended  by  difficulty.  The  con- 
fluent form  may  suggest  diphtheria,  especially  if  the  aphthous  lesions  de- 
velop first  or  chiefly  in  the  pharynx;  but  scattered  aphthae  elsewhere  in 
the  mouth  will  settle  the  question.  Ulcerative  stomatitis  appears  chiefly 
at  the  junction  of  the  teeth  with  the  gums,  and  the  breath  is  character- 
istically offensive.  There  is  also  in  this  a  tendency  to  hemorrhage  and 
to  breaking  down  of  the  mucous  membrane. 

Treatment.  Prophylaxis. — This  is  limited  to  the  keeping  of  the 
mouth  clean  and  the  general  health  good;  yet  with  our  ignorance  of  the 
exact  cause,  preventive  measures  are  unsatisfactory. 

Treatment  of  the  Attack. — Thorough  gentle  washing  should  be  em- 
ployed freely,  as  in  catarrhal  stomatitis,  with  a  cold  solution  of  boric 
acid  (10  per  cent.),  or  of  permanganate  of  potash  (1  :  10,000  or  stronger). 
If  the  healing  is  tardy  the  lesions  may  be  touched  carefully  with  burnt 
alum  or  nitrate  of  silver;  or  painting  the  lining  of  the  mouth  with  a  1 
per  cent,  solution  of  nitrate  of  silver  may  be  employed.  The  food  given 
should  be  soft  and  unirritating  and  preferably  cool. 


THRUSH  655 

THRUSH 

(Sprue) 

The  disease  has  been  known  since  early  times,  but  its  nature  not 
understood  until  revealed  by  the  studies  of  Berg^  in  1841  and  of  Miiller^ 
in  1842.  Its  frequency  has  been  much  diminished  as  a  result  of  the 
greater  care  for  cleanliness  now  exercised. 

Etiology. — The  affection  is  seen  almost  solely  at  an  early  age, 
especially  in  the  first  2  or  3  months  of  life,  although  it  may  occur  later  in 
marantic  or  neglected  subjects,  especially  in  institutions  for  infants;  and 
it  may  even  develop  in  vigorous  infants  in  perfect  health.  It  can  appear, 
too,  in  adult  life  in  the  course  of  debilitating  diseases.  Its  occurrence  in 
early  infancy  is  favored  by  the  greater  dryness  and  the  greater  degree 
of  rest  of  the  mouth  and  tongue  at  this  period.  The  presence  of  gastro- 
intestinal disorders  is  a  powerful  predisposing  factor,  as  is  catarrhal 
stomatitis.  Shght  injury  to  the  mouth  made  by  roughness  in  cleansing 
it  also  produces  the  unhealthy  local  condition  necessary  for  the  develop- 
ment of  the  parasite.  The  absence  of  cleanhness  acts  in  a  similar  man- 
ner. The  nature  of  the  diet  has  little  influence,  since  breast-fed  children 
may  also  be  attacked. 

That  the  malady  is  infectious  has  been  shown  beyond  question.  It 
can  certainly  be  acquired  from  unclean  rubber  nipples,  or  even  from  the 
maternal  nipple.  The  germ  consists  of  a  mould-fungus  of  the  class  of 
hyphomycetes,  but  its  exact  position  is  even  yet  undetermined  and  it  has 
been  variously  named.  It  was  first  described  by  Berg.^  Robin*  named 
it  the  oidium  albicans  and  Reess^  the  saccharomyces  albicans,  while  Plaut^ 
identified  it  with  the  monilia  Candida.  Under  the  microscope  can  be 
seen  long,  fine,  mycelial  threads  with  numerous  gonidia,  although  the 
organism  is  subject  to  considerable  variation.  There  are  mingled  with 
these  epithehal  cells,  red  and  white  blood-corpuscles  and  bacteria.  The 
fungus  is  present  in  many  normal  mouths  without  producing  an  infec- 
tion; may  be  found  readily  in  healthy  stools;  and  exists  to  a  certain  extent 
free  in  the  air.  The  germ  is,  therefore,  widespread  and  only  awaits 
favorable  conditions  for  its  development.  Outside  of  the  body  it  grows 
readily  in  a  solution  of  sugar  or  one  of  gelatine. 

Pathological  Anatomy. — The  parasite  enters  between  the  epi- 
thehal cells  and  develops  best  beneath  the  superficial  layer.  Thence 
spores  and  mycelial  threads  penetrate  the  diff'erent  lower  layers  of  the 
epithelium,  but  generally  do  not  extend  beyond  this.  The  process  is 
not  productive  of  pus.  The  infection  may  extend  to  the  tonsils  and 
pharynx  and  rarely  to  the  nasopharynx,  middle  ear,  esophagus,  stomach, 
intestines,  larynx,  trachea,  lungs  and  skin.  Even  the  walls  of  tlie  blood- 
vessels and  the  tissues  may  be  penetrated  in  some  cases  (Heller)^  and 
the  disease  may  exceptionally  be  spread  by  the  blood,  metastasis  occur- 
ring in  remote  parts  of  the  body,  as  the  spleen  and  kidneys  (Schmorl)^ 
or  the  brain  (Zenker).*  A  general  infection  by  thrush  has  been  reported 
by  Heubner.'" 

I  Jouni.  f.  Kinflerkr..  1847,  IX,  194. 
«  Arch.  f.  Anat.  u.  Physiol.,  1842,  193. 
•''  Loc.  cil. 

*  Hist,  natur.  dos  v<''p;(^taux  para.sit.,  Pari.'!,  1,S.'>.3,  4S8. 

*  Sitzim^ishcr.  (1.  iiH'd.-pliys.  Sociftiit ;  l-lrlanncii.  1S70-7,  IX,  190. 

*  Kollc  Hiid  Wassciiuaiiii.  Ilaiidl).  d.  path.  Alicroiiif?.,  1903,  I,  575. 
'  (')2  Vcrsamiid.  (h'litscli.  Xaturforsch.  \i.  Acrztc,  1889,  342. 

«  Contralh.  f.  Hact.  u.  Paiasitcnk.,  1890,  VI 1,  ;}29. 
»  Jahrcsb.  d.  Dmsdenor  Gosellsch.  f.  Natur.  u.  M.-ilk.,  1861-2,  51. 
»<•  Deutsclie  med.  Wochenschr.,  1903,  XXIX,  .")81. 


656  THE  DISEASES  OF  CHILDREN 

Symptoms.^ — The  characteristic  symptom  is  the  presence  of  the 
parasite  in  the  mouth.  Small  white  patches  develop  of  pin-point  size  and 
larger,  resembling  curdled  milk.  They  are  situated  chiefly  on  the  dorsum 
of  the  tongue,  but  the  lining  of  the  cheeks,  lips,  and  palate  is  also  a  favorite 
locality.  They  may  be  few  in  number  and  discrete,  but  oftener  are 
very  numerous  and  tend  to  coalesce,  forming  large  plaques.  The  patches 
are  covered  with  epithelium  and  somewhat  raised,  and  can  be  removed 
only  by  the  exercise  of  considerable  force,  a  raw,  slightly  bleeding  surface 
remaining.  The  surrounding  mucous  membrane  is  reddened.  As  the 
lesions  grow  older  they  become  more  yellowish  and  are  more  easily 
removable,  or  loosen  of  themselves.  The  mouth  is  rather  dry,  and  the 
reaction  of  the  sahva  is  generally  acid;  this  latter  being  probably  the  result 
of  the  growth  of  the  parasite  rather  than  a  favoring  cause,  since  the  fungus 
thrives  best  on  alkaline  or  neutral  media.  Nursing  is  painful  and  food 
often  refused;  and  swallowing,  too,  causes  pain  if  the  disease  extends  to 
the  fauces.  Gastrointestinal  disturbance,  although  often  the  predispos- 
ing cause,  may  sometimes  be  a  result  of  the  disease;  diarrhea  being  a 
frequent  symptom  and  producing  great  irritation  of  the  buttocks.  Vomit- 
ing may  occur  and  there  may  be  moderate  fever.  Any  marantic  condition 
previously  existing  is  increased  by  the  interference  with  the  taking  of 
food. 

Course  and  Prognosis.- — ^Under  suitable  treatment  in  comparatively 
healthy  infants,  the  duration  is  short,  lasting  only  1  or  2  days,  and  the 
prognosis  is  excellent.  In  debilitated  infants,  on  the  other  hand,  the 
disease  may  be  obstinate,  either  entirely  unyielding  or  continually 
recurring  after  apparent  improvement.  In  such  cases  thrush  adds  to  the 
debility  and  hastens  the  fatal  ending.  The  prognosis  is  also  less  favor- 
able when  the  process  spreads  to  the  pharynx.  In  rare  instances  death 
has  been  caused  by  occlusion  of  the  esophagus. 

Diagnosis. — Thrush  can  scarcely  be  confounded  with  any  other 
disease,  although  superficial  examination  may  cause  it  to  be  mistaken 
for  curdled  milk.  The  latter,  however,  is  easily  removable  and  con- 
sequently recognized  without  difficulty.  Patches  in  the  pharynx 
might  suggest  diphtheria,  but  the  presence  of  the  fungus  in  the  mouth 
as  well  excludes  this  malady.  Microscopic  examination  readily  removes 
all  uncertainty. 

Treatment. — Prophylaxis  is  most  important,  and  is  readily  attained 
by  cleanliness  of  the  mouth  and  of  everything  which  goes  into  it,  including 
rubber-nipples  and  the  maternal  breast.  Systematic  cleansing  must  be 
done  with  the  greatest  gentleness  in  order  to  prevent  the  development  of 
abrasions ;  absorbent  cotton  wrapped  about  the  finger  or  on  an  apphcator 
being  employed  rather  than  coarser  material. 

The  treatment  of  the  attack  itself  consists  likewise  of  careful,  very 
gentle,  frequent  cleansing  of  the  mouth.  The  patches  may  be  cautiously 
rubbed  away  with  pledgets  of  cotton  moistened  with  an  alkahne  solution, 
as  of  borax  (10  per  cent.),  or  bicarbonate  of  soda  (6  per  cent.),  and  the 
mouth  bathed  3  or  4  times  a  day  with  some  remedy  destructive  to 
the  fungus.  Among  these  substances  are  permanganate  of  potash 
(1:5000  or  stronger),  liquor  formaldchydi  (1  or  2: 100),  or  nitrate  of  silver 
(1  per  cent.).  The  old-time  borax-and-honey  should  be  avoided, 
since  any  saccharine  substance  favors  the  growth  of  the  fungus.  In 
its  place  a  25  per  cent,  solution  of  borax  in  glycerin  may  be  used.  Such 
constitutional  treatment  should  be  -  employed  as  the  other  symptoms 
present  demand. 


ULCERATIVE  STOMATITIS  657 

ULCERATIVE  STOMATITIS 

This  form  of  inflammation  of  the  mouth  is  one  of  the  severer  varieties, 
much  less  common  than  those  previously  described.  It  has  been  recog- 
nized as  a  distinct  affection  only  since  the  last  part  of  the  18th  century. 

Etiology. — Age  is  an  important  factor,  the  disease  being  most  fre- 
quent at  from  4  to  8  years  and  being  seldom  seen  before  this  period.  It 
appears  not  to  develop  until  the  teeth  have  erupted.  Imperfect  hj-giene, 
uncleanliness  of  the  mouth,  and  any  debilitating  influence  strongly 
predispose.  The  disease  is  consequently  much  more  common  among 
the  poor  than  among  those  of  better  social  condition.  It  is  a  not  infre- 
quent sjaiiptom  of  scurvy,  and  may  be  an  attendant  upon  diphtheria, 
measles,  scarlet  fever,  typhoid  fever,  and  other  infectious  diseases. 
The  presence  of  carious  teeth  is  a  predisposing  cause,  and  it  may 
be  produced  by  metallic  poisons,  especially  mercury.  It  would  seem 
that  the  malady  does  not  often  attack  those  in  previousl}-  good  general 
health  and  with  the  mucous  membrane  of  the  mouth  in  a  normal  condi- 
tion. It  often  appears  in  epidemic  form  in  hospital  wards,  indicating 
that  it  depends  upon  some  specific  transmissible  germ.  According 
to  the  investigations  of  Bernheim  and  PospischilU  a  fusiform  bacillus 
and  a  spirochete  identical  with  those  seen  in  ulcero-membraneous 
angina  (p.  682)  were  found  in  all  but  2  of  30  cases  of  ulcerative  stomatitis. 
The  bacillus  is  long  and  narrow,  larger  than  the  diphtheria  bacillus,  and 
with  pointed  ends  (bacillus  fusiformis).  Two  are  often  joined  end  to  end. 
This  germ  is  always  accompanied  by  a  spirochete  much  longer  and 
thinner  than  the  bacillus. 

Pathological  Anatomy.- — The  lesions  usually  begin  on  the  free 
border  of  the  gums.  There  first  occurs  hyperemia  with  swelling  from  in- 
flammatory exudate;  the  gum  becoming  loosened  from  the  teeth,  much 
swollen,  bleeding  easily,  and  exhibiting  a  reddish-purple  color.  Ulcera- 
tion now  appears  upon  the  free  border,  indicated  by  a  narrow,  yellowish 
line,  due  to  the  development  of  necrosis  in  the  superficial  layer  of  the 
mucous  membrane.  The  process  rapidly  advances  in  breadth  as  well 
as  in  depth,  and  commonly  spreads  by  contiguity  to  the  mucous  mem- 
brane of  the  cheek  and  lip.  The  ulcers  which  are  produced  are  cov- 
ereti  by  a  grayish  or  yellowish  material,  which  is  firmly  adherent  to  the 
subjacent  tissue.  As  recovery  takes  place  the  necrotic  tissue  loosens 
and  a  new  epithelial  covering  forms.  In  the  most  severe  cases  the  necro- 
sis extends  into  the  alveolar  process  of  the  jaw,  the  roots  of  the  teeth  may 
be  exposed,  and  the  teeth  themselves  fall  out. 

Symptoms. — The  character  of  the  local  process  has  already  been 
described.  The  original  lesion  in  most  cases  is  situated  on  the  external 
aspect  of  the  gums,  usually  next  to  the  incisoi'  teeth,  sometimes  the 
canines  or  molars,  and  oftenest  in  the  lower  jaw  upon  one  side  only.  In 
most  instances  the  disease  spreads  to  the  nuicous  membrane  of  the  cheek 
or  lip  in  contact  with  the  original  lesion.  The  edges  of  the  tongue  are 
not  infrequently  involved.  The  process  may  extend  to  the  ton&ils  and 
occasionally  the  palate,  or  may  sometimes  originate  there.  (See  Ulcero- 
membranous Tonsillitis,  p.  (>H2.)  The  first  symptoms  noticed  are  usu- 
ally salivation  and  a  very  offensive  odor  of  the  l)i('atli.  Tlie  lesions  are 
painful  and  tender  and  food  is  refus(>d,  |)artly  from  this  reason  and  partly 
from  loss  of  appetite.  The  tongue  is  coated,  swollen  and  often  tooth- 
marked.     The  ulcerated  area  bleeds  easily  if  disturbed  l)y  examination. 

1  .lal.rb.  f.  Kiiulerlicilk.,  189S,  XLVI,  VM. 
42 


658  THE  DISEASES  OF  CHILDREX 

Constitutional  symptoms  may  be  absent,  or  in  severer  cases  there  may  be 
fretfulness,  fever,  pallor,  swelling  and  tenderness  of  the  submaxillary 
lymphatic  glands,  and  decided  debility,  or  even  sjanptoms  of  a  septic 
nature. 

Complications. — Vomiting  and  diarrhea  are  sometimes  seen,  perhaps 
the  result  of  swallowing  the  secretion  of  the  ulcers.  More  or  less  catarrhal 
stomatitis  is  common  and  aphthous  stomatitis  may  likewise  occur. 
Noma  maj'  be  a  sequel. 

Course  and  Prognosis. — In  average  cases  under  proper  treatment 
the  attack  lasts  7  to  10  days,  the  slough  separates,  hemorrhage  and  pain 
cease,  the  salivation  and  the  odor  disappear,  and  recovery  is  complete. 
If  untreated,  however,  the  disease  may  continue  sometimes  for  months. 
In  the  severer  cases,  too,  where  the  periosteum  becomes  involved,  the 
course  is  more  prolonged.  Even  the  milder  cases  occasionally  become 
somewhat  chronic  in  spite  of  treatment.  Relapses  are  prone  to  occur. 
In  the  exceptional  instances  which  end  fatally,  death  is  due  to  exhaustion 
or  to  some  complicating  cause,  such  as  sepsis  or  noma. 

Diagnosis.- — This  is  unattended  by  difficulty  in  most  cases.  The 
situation  of  the  lesion  and  the  offensive  odor  are  characteristic.  Aph- 
thous ulcers  may  in  some  cases  first  appear  upon  the  free  borders  of  the 
gums  and,  if  confluent,  may  at  first  cause  uncertainty.  The  patches, 
however,  are  superficial  and  other  discrete  lesions  in  the  mouth,  together 
with  the  absence  of  the  odor,  make  the  diagnosis  clear.  Diphtheria  of 
the  mouth  is  uncommon,  nearly  always  secondar}^  to  that  of  the  fauces, 
and  presents  really  no  close  resemblance.  Noma  is  characterized  by  the 
extensive  induration  usually  in  the  cheek,  and  by  the  black,  gangrenous 
tissues.  I  have  known  severe  ulcerative  stomatitis  with  involvement  of 
the  alveoh  and  loss  of  teeth  to  be  designated  noma ;  but  the  process  in  the 
latter  condition  is  much  more  severe.  The  diagnosis  of  the  cause  of 
stomatitis  should  also  be  made  when  possible,  particularly  with  refer- 
ence to  the  existence  of  some  constitutional  condition,  the  influence  of 
mercury,  or  the  presence  of  scurvy. 

Treatment.  Prophylaxis. — This  consists  in  the  removal  of  all  pre- 
disposing causes  by  improving  the  general  health,  attending  to  cleanliness 
of  the  mouth,  the  treatment  of  carious  teeth,  and,  in  hospital  practise, 
the  isolation  of  those  already  attacked.  Particular  caution  must  be 
observed  after  the  occurrence  of  acute  infectious  diseases. 

Treatment  of  the  Attack. — The  cause  must  be  sought  for  and  removed 
if  possible,  and  measures  must  be  taken  to  improve  the  general  health,  to 
guard  against  relapses  by  the  administration  of  tonic  treatment,  often 
with  iron,  and  especially  to  see  that  sufficient  food  is  taken,  even  by 
gavage  if  necessary.  The  food  should  naturally  be  of  an  unirritating, 
cool,  and  easily  digestible  nature.  For  local  treatment  frequent  washing 
of  the  mouth  with  a  solution  of  permanganate  of  potash  (1 :  1000)  or  with 
peroxide  of  hydrogen  (10  to  50  per  cent.)  should  be  used.  A  solution  of 
nitrate  of  silver  (5  to  10  grains  (0.32  to  0.65) :  1  ounce  (30),  is  sometimes 
serviceable  in  obstinate  cases.  The  best  and  almost  a  specific  treatment 
for  the  disease  is,  however,  the  administration  of  chlorate  of  potash.  As 
this  is  promptly  excreted  by  the  saliva,  it  may  be  given  internally  in  doses 
of  3  grains  (0.19)  every  2  hours  for  a  child  of  4  years.  It  should  be  well 
diluted,  as  its  contact  with  the  lesions  causes  some  pain.  The  possible 
deleterious  effects  of  the  drug  must  be  borne  in  mind.  All  carious  teeth 
or  portions  of  necrosed  bone  must  be  removed  and  a  stronger  solution  of 
nitrate  of  silver  or  other  caustic  applied  carefully  to  the  diseased  locality. 


GANGRENOUS  STOMATITIS  659 

GANGRENOUS  STOMATITIS 
(Noma.     Cancrum  Oris) 

The  term  "noma"  is  of  a  wider  application  than  "gangrenous  stoma- 
titis" since  a  condition  of  the  same  natm-e  as  that  occurring  in  the  mouth 
is  occasionally  seen  in  other  parts  of  the  body,  as  the  ear,  nose,  genitals,  or 
anus,  and  is  properly  designated  by  this  term.  The  description  which 
follows  apphes  to  the  mouth  only.  The  disease  appears  to  have  been 
more  common  in  earlier  times  and  at  present  is  fortunately  rare,  inasmuch 
as  it  is  one  of  the  most  dreadful  of  the  disorders  of  early  hfe.  Woroni- 
chin^  reported  but  22  cases  occurring  among  8286  sick  children  in  hospital- 
practice,  and  Ranke^  gave  even  a  lower  incidence  of  2  in  from  4000  to 
5000  patients. 

Etiology. — Age  is  an  important  predisposing  factor,  the  disease 
being  oftenest  seen  between  2  and  5  years  of  age.  There  is  no  certain 
proof  of  any  contagiousness,  although  there  is  a  great  possibility  that 
this  exists.  Local  epidemics  of  noma  in  infant's  homes  or  hospitals 
have  been  described,  as  by  Blumer  and  MacFarlane^  and  by  Neuhof,^ 
not  all  the  cases,  however,  being  Hmited  to  the  mouth.  It  is  less  fre- 
quent in  infants,  although  cases  are  recorded  in  the  early  months  of  life. 
The  46  cases  reported  by  Woronichin,'  including  those  seen  both  in  hos- 
pital and  dispensary  practice,  were  from  1  to  2  years,  8;  2  to  3  years, 
12 ;  3  to  4  years,  6 ;  4  to  5  years,  7 ;  5  to  6  years,  4 ;  6  to  7  years,  6 ;  7  years, 
1;  8  years,  1;  12  years,  1.  Previous  bad  health  is  almost  a  necessity. 
The  affection  is  met  with  oftener  after  typhoid  fever  and  especially  after 
measles  than  under  any  other  conditions,  although  it  may  follow  per- 
tussis, scarlet  fever,  diphtheria,  enteritis,  tuberculosis  or  other  affection 
occasioning  general  debihty.  In  the  same  way  residence  in  damp,  un- 
healthy localities,  or  the  presence  of  ulcerative  stomatitis,  may  act  as  a 
predisposing  cause.  That  the  affection  is  dependent  upon  the  action  of 
some  germ  seems  beyond  question,  but  the  nature  of  this  is  not  certainly 
known,  and  it  is  very  probable  that  more  than  one  microorganism  is 
capaVjle  of  producing  it,  or  a  symbiosis  of  a  number  of  organisms.  Vari- 
ous pus-producing  germs  have  been  found  in  the  gangrenous  tissue. 
Certain  microorganisms  have  been  reported  as  specific.  Schimmclbusch^ 
described  a  l)acillus,  sometimes  short  and  sometimes  in  long  threads; 
Ranke^  found  cocci;  and  growths  of  the  leptothrix  type  have  been 
observed.  A  bacillus  identical  with,  or  closely  resembling,  the  diphtheria- 
germ  has  been  seen  in  a  number  of  instances,  as  in  2  case  of  my  own 
reported  by  Sailer.**  Hellcsen,'-'  observed  a  diplococcus,  and  Durante'"  a 
staphylococcus.  A  number  of  observers  have  noted  the  fuso-spirillary 
germs  characteristic  of  ulcerative  stomatitis  and  ulcero-memhraiious 
angina.  These  w(!re  seen  in  1  of  my  cases  which  began  in  tiie  tonsil. 
Pathological  Anatomy. — The  process  is  a  rapidly  spreading 
gangrene  with  the  ciiaractcristics  of  this  condition  wherever  found. 
There  is  little  disposition  to  limitation  shown,  except  in  the  favorable 

«  Jahrb.  f.  Kintlcrheilk.,  1887,  XXVI,  IC.l. 
•^.lahrb.  f.  Kindcrlioilk.,  1888,  XXVII,  3U9. 
3  Amcr.  Journ.  Med.  8ci.,  1901,  CXXII,  .'>27. 
'  Amcr.  Journ.  Med.  Sci.,  1910,  CXXXIX,  705. 
'  Ijoc.  cit. 
»  Deut.scho  incd.  Wochenschr.,  1889,  XV,  510 

8  .Vmer.  .Journ.  M.-d.  Sci.,  1902,  CXXllI,  59. 
» .lahrb.  f.  Kiiidorlieilk.,  1908,  LXVII,  294. 
'0  La  Pediatria,  1902,  X,  232. 


660 


THE  DISEASES  OF  CHILDREN 


but  rare  cases  where  a  line  of  demarcation  forms.  It  is  probable  that  the 
mucous  membrane  is  first  attacked,  althoujjh  sometimes  the  process 
would  appear  to  have  started  in  the  substance  of  the  cheek;  and  very 
exceptionally  the  lesion  is  first  seen  on  the  cutaneous  surface. 

Symptoms. — The  commonest  situation  of  the  disease  is  the  cheek 
opposite  the  molar  teeth  and  upon  one  side  only,  rarely  both  sides  being 
involved  simultaneously.  Often,  however,  the  gum  or  the  inner  surface 
of  the  hps  is  the  primary  seat.  Examination  of  the  oral  cavity  reveals  a 
small  ulcer  covered  by  a  dark-grey  slough.  This  spreads  in  area  and 
in  depth,  and  produces  a  black,  gangrenous  area,  with  the  surrounding 
tissue  edematous  and  swollen.     Meanwhile  induration  develops  in  the 


Fig.  227. — GAX(JUK.\<jr.s  Stomatitis  Be<;inni\(;  in  the  Cheek. 
Child  of  7   years,    admitted    to    the    Children's    Hospital    of    Philadelphia,     suffering 
apparently  from  typhoid  fever.     Gangrenous  process  began  Dec.  10,  with  swelling  of  the 
right  cheek;  Dec.  19,  almost  entire  cheek  involved;  Dec.  23,  lower  lip  and  chin  attacked; 
Dec.  24,  death. 


substance  of  the  cheek,  which,  seen  from  without,  is  much  swollen, 
shining,  pale,  and  hard  to  the  touch.  Soon  the  skin  over  it  becomes  red, 
and  then  blackish  (Fig.  227)  and  the  check  perforates.  The  process 
follows  a  similar  course  when  the  gums  are  affected.  Wherever  the 
primary  seat,  the  destructive  process  spreads  with  astonishing  rapidity; 
involving  the  alveolar  process;  causing  the  teeth  to  loosen  and  fall; 
attacking  often  the  tongue,  palate,  lips,  or  a  large  portion  of  one  side  of 
the  face;  and  finally,  in  the  worst  cases,  extending  to  the  other  side 
(Figs.  228,  229).  Often  the  first  symptom  noticed  is  the  excessively 
offensive  odor  of  the  breath,  and  as  the  case  progresses  this  becomes 
intense  and  very  penetrating.  The  general  condition  of  the  patient  is 
but  little  affected  at  first,  but  as  the  disease  advances  debility  becomes 


GA  NGRENO  US  S  TO  MA  TI TIS 


661 


Fig.  228. — Gangrenous  Stomatitis  Beginning  in  the  Lip. 
Same  case  as  in  Fig.  230.     Photograph  taken  soon  after  admission  to  the  Children's 
Hospital  Oct.  25. 


V 


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Fig.  22S. — CiA.\t.Hfc.\ui  .--  Si.»ma  1 1 1 1-  11i..,i.\mng  in  the  Lip. 
Same  case  as  in  Fig.  228.     PhotoRraph  taken  a  few  days  later. 


662 


THE  DISEASES  OF  CHILDREN 


great,  the  pulse  is  feeble,  delirium  and  insomnia  may  occur,  diarrhea 
develop,  and  fever  of  an  uncharacteristic  type  be  present  (Fig.  230),  and 
the  symptoms  are  those  of  sepsis.  Pain  is  but  little  marked.  The  sub- 
maxilliary  lymphatic  glands  may  be  enlarged. 

Course  and  Prognosis. — The  course  of  the  disease  is  generally 
verj''  rapid,  visible  changes  taking  place  almost  from  hour  to  hour. 
Perforation  may  sometimes  occur  in  24  hours,  but  oftener  not  before  3 
or  4  days.  The  usual  duration  is  5  to  10  daj^s.  Sometimes,  however, 
the  course  is  much  slower  and  the  induration  may  last  several  daj^s  before 
gangrenous  changes  appear.  In  cases  which  recover  a  line  of  demarca- 
tion forms  and  the  slough  is  thrown  off  after  8  to  10  days,  sometimes 


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Fig.  230. — Gangrenous  Stomatitis. 
Lena  P.,  aged  2  years,  admitted  to  the  Children's  Hospital  of  Philadelphia,  Oct.  25, 
with  sloughing  in  the  right  half  of  the  upper  lip;  Oct.  28,  gangrene  has  extended  rapidly, 
and  now  involves  all  the  region  of  the  mouth  (Fig.  229),  extending  within  it  and  perfo- 
rating the  left  cheek;  thorough  cauterization  on  this  date;  Nov.  2,  died. 


without  perforation,  occurring,  although  this  is  exceptional.  The  great 
majority  of  cases  die  either  from  exhaustion  or  from  a  complicating  pneu- 
monia. At  the  best  75  per  cent,  of  them  end  fatally;  and  when  re- 
covery does  occur  it  is  nearly  always  with  extensive  deformity  remaining. 
The  more  widespread  the  lesion  and  the  poorer  the  general  health  of  the 
patient,  the  more  serious  is  the  outlook. 

Complications.^ — ^Bronchopneumonia  is  common;  abscess  or  gan- 
grene of  the  lung  .sometimes  occurs;  severe  hemorrhage  is  rare.  Diarrhea 
is  so  frequent  that  it  is  to  be  regarded  rather  as  a  symptom  of  the  disease. 

Relapse  and  recurrence  have  been  very  occasionally  seen. 

Diagnosis. — A  mistake  in  diagnosis  can  hardly  be  made.  Ulcerative 
stomatitis  does  not  produce  a  gangrenous  slough  even  when  severe  and 
causing  necrosis  of  the  jaw,  and  does  not  involve  the  skin.     It  is  only 


SECONDARY  STOMATITIS  663 

when  noma  complicates  a  previously  existing  ulcerative  stomatitis  that 
it  is  difficult  to  determine  the  time  of  onset  of  the  former. 

Treatment.  Prophylaxis. — -The  maintenance  of  the  general  health 
and  the  careful  attention  to  the  mouth  in  the  course  of  infectious  dis- 
eases or  in  any  form  of  stomatitis  is  of  the  greatest  importance.  Other 
children  should  be  separated  from  a  patient  with  noma. 

Treatment  of  the  Attack.^ — -Prompt  employment  of  surgical  inter- 
ference by  thorough  excision,  with  subsequent  cauterization,  offers  most 
hope  of  arresting  the  disease.  The  cauterization  is  best  done  by  heat 
or  nitric  acid,  carbolic  acid,  or  a  paste  of  chloride  of  zinc.  Nicoll^ 
reports  a  case  of  recovery  following  the  intravenous  injection  of  salvarsan. 
Exposure  to  rays  from  a  red  electric  lamp  was  successful  in  the  hands  of 
Motschan.2 

SIMPLE  UCLERATION  OF  THE  MOUTH 

(Herpetic  Stomatitis,  etc.) 

By  this  term  may  be  designated  the  small  ulcers,  usually  single  or 
few  in  number,  which  frequently  develop  as  a  result  of  catarrhal  stomatitis 
or  from  other  causes,  including  digestive  disturbances.  In  exceptional 
cases  the  lesions  may  be  very  numerous  and  widespread  over  the  oral 
cavity,  as  in  a  case  reported  by  Scheltema.^  Some  of  the  cases  are  prob- 
ably closely  allied  to  herpes.  The  infectious  diseases,  such  as  measles, 
typhoid  fever,  and  the  like,  may  sometimes  produce  the  condition,  and 
the  eruption  of  varicella  in  the  mouth  might  be  classed  here.  The  process 
differs  from  true  ulcerative  stomatitis  in  the  situation  and  the  usual 
smallness  in  size  and  extent  of  the  lesions.  The  ulcers  are  unlike  those 
of  aphthous  stomatitis  in  that  they  exhibit  a  shallow  depression  with 
superficial  necrosis  rather  than  the  firm,  elevated  mass  of  the  latter  disease. 
They  probably  begin  in  many  cases  as  vesicles,  but  the  covering  mucous 
membrane  promptly  ruptures.  They  are  benefited  by  cleanliness  and 
the  application  of  a  1  per  cent,  solution  of  nitrate  of  silver. 

SECONDARY  STOMATITIS 

Here  may  be  included  certain  forms  not  already  mentioned,  which  are 
secondary  manifestations  to  other  diseases: 

Gonorrheal  Stomatitis. — This,  has  been  reported  as  affecting  the 
new  born,  the  infection  taking  place  from  the  maternal  passage  during 
birth  (Rosinski).''  It.  is  also  acquired  in  other  ways,  as  by  self-infection 
from  a  gonorrheal  vulvovaginitis.  A  whitish  deposit  appears  in  the 
mouth,  especially  upon  the  palate  and  the  tongue  and  the  gonococcus 
is  discoveraljle  on  microscopic  examination.  Recovery  takes  place  in 
a  few  days.  Cleanliness  is  the  only  treatment  required,  or  perhaps  the 
api)Iication  of  a   I  pci-  ('(Mit.  solution  of  nitrate  of  silver. 

Diphtheritic  Stomatitis. — This  form  of  stomatitis  is  a  rare  and  dan- 
gerous development,  the  pseudomembrane  appearing  on  the  lining  of  the 
cheeks,  lips,  or  tongue.  It  occurs  only  in  the  worst  cases  of  diphtheria. 
A  faucial  involvement  nearly  always  precedes  it.  In  one  instance  I 
found  the  lesion  in  tlie  mouth  before  discoverable  in  the  piiarynx.  The 
pseudo-membrane    has    tiie    usual    ap])earance    of    diphtiicria    of   other 

»  Archives  of  Pediatrics,  1911,  XX VIII,  912. 
*  Arch.  f.  KinderiuMlk.,  1904-."},  XL,  241. 

'  Mcfl.   Maandschr.  v.   Wrlosk.,  Vrouvenz.  en    Kindcrgenecsk.,  Ill,  524.     Rof., 
Jahrb.  f.  Kinderh.,  1915,  LXXXI,  546. 

<Deutsch.  ined.  Wochenschr.,  1S91,  XVII,  .')(i9 


664  THE  DISEASES  OF  CHILDREN 

localities.  It  is  to  be  distinguished  only  from  extensive  confluent  aph- 
thous stomatitis,  and  this  is  usually  easily  done  if  attention  be  paid  to 
other  symptoms. 

A  pseudomembranous  stomatitis,  other  than  diphtheritic,  may  be 
the  result  of  trauma,  especially  from  the  action  of  hot  or  caustic  fluids 
in  the  mouth,  or  be  produced  by  other  germs,  as  the  pneumococcus, 
perhaps  in  the  course  of  pneumonia;  or  by  the  staphylococcus  or  strep- 
tococcus in  connection  with  sepsis  elsewhere.  The  constitutional 
symptoms  are  severe. 

Syphilitic  stomatitis  has  already  been  considered  in  discussing 
syphilis.  It  shows  itself  in  the  form  of  mucous  placques  and  in  fissures 
at  the  labial  commissures,  or  sometimes  in  acquired  cases  in  the  form  of 
the  primary  lesion  within  the  buccal  cavity. 

BEDNAR'S  APHTHiE 
(Pterygoid  Ulcer) 

This  condition  first  described  by  Bednar^  is  in  no  way  related  to 
aphthous  stomatitis,  and  the  name  is  in  so  far  confusing.  Strictly  speak- 
ing, it  is  an  affection  of  the  palate. 

Etiology. — It  is  seen  only  in  infants  in  the  early  months  of  life 
and  is,  in  reality,  a  trauma  produced  by  too  forcible  cleansing  of  the 
mouth,  or  by  the  pressure  of  too  long  a  rubber  nipple.  The  mere  act  of 
sucking  by  a  child  with  catarrhal  stomatitis  may  cause  it,  the  mucous 
membrane  of  the  palate  being  tightly  stretched  and  anemic  and  conse- 
quently very  easily  injured. 

Symptoms.— These  consist  of  the  local  lesion,  which  is  a  superficial 
ulcer  situated  on  the  posterior  portion  of  the  hard  palate  in  the  median 
line,  or  upon  one  or  the  other  side  of  it.  Sometimes  there  are  two  ulcers 
symmetrically  placed,  one  on  each  side  of  the  raphe.  The  ulcer  is 
shallow,  one-quarter  to  one-half  inch  in  diameter  and  covered  by  a 
greyish  or  yellowish-white  exudation.  It  is  painful  and  causes  difficulty 
in  sucking,  with  consequent  progressive  loss  of  weight  and  strength. 
Catarrhal  stomatitis,  thrush,  or  gastrointestinal  disturbance  may  occur 
as  a  complication. 

Course  and  Prognosis. — The  course  of  the  disease  is  usually 
favorable,  the  ulcer  healing  in  a  few  days,  or  in  1  or  2  weeks.  In  cases 
in  infants  with  great  malnutrition  it  may  prove  very  obstinate  and  the 
bone  may  become  involved.  The  lesion  may  extend  and  a  pseudodipthe- 
ritic  membrane  or  ulcerative  condition  develop,  and  the  infant  die  of 
sepsis  or  debility. 

Treatment. — This  consists,  first  of  all,  in  preventing  the  development 
of  the  lesion  by  the  avoidance  of  any  possible  mechanical  irritation. 
A  similar  caution  will  usually  permit  of  rapid  healing  of  an  ulcer  already 
present.  In  more  obstinate  cases  very  careful,  frequent  washing  with  a 
solution  of  boric  acid  may  be  employed,  with  occasional  application 
of  one  of  nitrate  of  silver  (  1  per  cent.).  A  weak  solution  of  cocaine  (1 
per  cent.)  may  be  carefully  applied  before  nursing  if  pain  is  great,  but 
much  caution  is  required  against  constitutional  effects. 

DISEASES  OF  THE  TONGUE 

Apart  from  the  disorders  of  the  tongue  seen  in  some  affections  of  the 
mouth,  and  in  those  nervous  diseases  which  involve  the  organ,  several 
conditions  deserve  consideration  here: — 

Macroglossia. — This  is  an  anomaly  rarely  seen  as  an  affection  exist- 
ing alone  and  of  congenital  origin.     In  such  cases  it  is  in  reality  a  diffuse 

1  Die  Krankheit.  d.  Neugeb.  u.  SiiugL,  1850,  I.  105. 


DISEASES  OF  THE  TONGUE  665 

lymphangioma,  and  ma}"  reach  such  size  that  the  tongue  cannot  be 
retained  in  the  mouth  and  interferes  with  nursing  and  later  with  speech. 
Enlargement  of  another  nature,  not  congenital  and  of  a  less  degree,  is 
seen  in  cretinism,  mongolian  idiocy  and  acromegaly.  The  lesion  here 
is  a  hypertrophy  of  the  muscles  and  of  the  interstitial  connective  tissue. 
The  treatment  of  congenital  macroglossia  is  surgical,  if  the  size  inter- 
feres with  the  taking  of  food.  If  it  depends  upon  cretinism,  the  thyroid 
treatment  suitable  for  this  disease  is  indicated. 

Very  rareh'  other  congenital  defects  of  the  tongue  are  encountered, 
among  them  congenital  absence  of  a  portion  of  the  organ,  or  in  other  cases 
a  split  or  bifid  tongue. 

Tumors. — These  are  not  of  frequent  occurrence.  Among  them  may 
be  mentioned  dermoid  cysts,  diffuse  or  more  localized  angiomata  and 
lymphangiomata,  and  growths  consisting  of  misplaced  thyroid  tissue. 
Surgical  treatment  is  indicated. 

Tongue=tie. — B}^  this  title  is  designated  a  shortening  of  the  fraenum 
linguae,  making  it  impossible  to  protrude  the  tongue  beyond  the  teeth 
to  the  normal  extent.  It  varies  considerabl}^  in  degree.  As  a  rule  it 
gives  no  trouble,  but  in  well-developed  cases  may  interfere  with  suck- 
ing and  later  with  perfect  articulation.  Such  a  condition  is,  however, 
certainly  most  uncommon.  Treatment  consists  in  nicking  the  edge  of 
the  frenum  with  blunt-pointed  scissors  and  in  tearing  through  the  remain- 
ing membrane.  In  this  way  the  occasional  danger  of  hemorrhage  is 
averted,  except  in  bleeders. 

Ulceration  of  the  Frenum. — This  is  often  seen  in  pertussis,  or  in 
other  conditions  attended  by  violent  coughing.  It  is  the  result  of  the 
forcible  impact  of  the  frenum  against  the  lower  incisor  teeth.  It  occa- 
sionally, however,  appears  in  other  conditions  also,  or  without  discover- 
able cause  in  nursing  infants.  The  application  of  a  weak  solution  of 
nitrate  of  silver  soon  produces  a  cure. 

Sublingual  Fibroma  {Sublingual Granuloma ;  Riga's  Disease;  Fede's 
Disease). — This  affection  appears  to  be  of  not  infrequent  occurrence  in 
Italy,  and  a  few  cases  have  been  reported  in  Poland,  France,  Germany, 
Austria,  and  elsewhere.  A  case  occurring  in  America  was  described  by 
Amberg^  in  an  infant  of  American  descent.  The  first  description  to 
attract  attention  was  by  Riga.'-  Wh}-  the  disease  should  be  seen  espe- 
cially in  Italy  is  not  yet  explainable. 

Etiology  and  Pathology. — The  disorder  is  seen  only  in  the  1st  year 
of  life,  ami  especially  the  latter  portion  of  this,  after  the  lower  central 
incisor  teeth  have  erupted.  It  results  from  irritation  produced  in  the 
action  of  sucking,  through  the  friction  of  the  neighborhood  of  the  frenum 
of  the  tongue  against  the  teeth,  or  against  the  haid  ridge  of  gum  if  the 
teeth  have  not  appeared.  An  inflammation  results,  with  hypeiplasia  of 
the  tissues,  and  an  indurated,  small,  tumoi-like  body  of  the  nature  of  a 
papilloma  is  produced  by  the  fibrinous  infiltration.  Later  a  superficial 
ulcer  may  form  in  cases  of  long  duration,  and  a  superficial  small-celled 
infiltration  results  with  the  characteristics  of  a  granuloma.  The  devel- 
opment of  the  disease  is  not,  as  a  rule,  influenced  by  any  previous  dis- 
turbance of  health.  Other  disorders  nuiy  accompany  it  but  l)ear  no 
etiological  relationship,  although  they  may  influence  the  duration  of 
the  process. 

Symptoms. — There  are  generally  none  other  than  the  sublingual 
growth.     The.    earliest    appearance    is    that    of   an    indinated,    greyish, 

»  Anier.  Journ.  Mod.  Sci.,  1903,  CXXVI,  -J.")?. 

^Moviincnto  inedico-chirurnico,  ISSl,  XIll,  22.     lluf.  Ainhorg. 


666 


THE  DISEASES  OF  CHILDREN 


opaque,  hard,  somewhat  flattened  elevation,  which  increases  rapidly  in 
size  until  it  reaches  perhaps  one-quarter  to  1  inch  in  diameter,  situ- 
ated transversely  at  the  position  of  the  frenum  (Fig.  231).  The  central 
region  is  grey,  and  the  remaining  portion  redder  in  color.  The  duration 
of  the  lesion  may  be  weeks  or  months,  and  the  prognosis  is  entirely 
favorable.  In  subjects  with  debilitating  diseases  it  may  last  much 
longer,  but  will  finally  disappear,  unless  the  complicating  affection  is 
the  cause  of  death. 

The  diagnosis  is  to  be  made  only  from  sublingual  ulceration,  such  as 
is  seen  often  in  pertussis.  In  sublingual  fibroma,  however,  the  process 
is  hyperplastic,  and  any  ulceration  present  is  superficial. 


Fig.  231. —  Sublingual  Fibroma. 
(Amberg,  Amer.  Jour.  Med.  Sci.,  1903,  CXXVI,  257.) 


Treatment. — This  consists  chiefly  in  the  employment  of  boric  acid 
washes  and  the  application  of  tincture  of  iodine.  In  obstinate  cases  it 
may  be  necessaiy  to  remove  the  central  incisor  teeth.  In  debilitated 
subjects  every  measure  should  be  employed  to  improve  the  general  health. 

Black  Tongue  {Nigrities  Linguce). — Black  tongue  is  not  a  common 
affection,  Brosin^  having  been  able  to  collect  the  published  reports  of 
only  about  40  instances.  An  interesting  case  in  a  child  of  2  years  is 
illustrated  by  Gottheil.^  Its  cause  is  not  known  with  certainty.  The 
etiological  action  of  a  bacterium  or  of  a  mould  has  been  invoked,  as  has 
the  existence  of  a  hyperplasia  of  the  epithelial  layer  of  the  filiform  papillae, 
with  subsequent  hardening  and  change  of  color  by  pigmentation.  The 
lesion  appears  in  the  form  of  irregular  areas  situated  chiefly  near  the  base 
of  the  tongue,  or  running  forward  in  a  long  streak  toward  the  tip.  The 
black  area  may  be  either  smooth  or  of  very  decidedly  hairy  appearance 
if  the  papillie  are  unusually  long.  To  these  latter  cases  the  title  "black 
hairy  tongue^'  has  been  given.     There  are  no  subjective  symptoms  of 

1  Die  schwartze  Haarzunge,  1888. 

2  Arch,  of  Pediat.,  1899,  XVI,  255. 


DISEASES  OF  THE  TONGUE  667 

importance ;  seldom  more  than  a  sense  of  dryness.  The  disease  sometimes 
disappears  quickly,  but  is  oftener  very  chronic,  lasting  perhaps  for  years. 
In  the  line  of  treatment,  mouth  washes  of  borax,  hj-posulphite  of  soda, 
or  hydrogen  dioxide  may  soften  the  papillae  and  remove  the  color;  or, 
if  these  are  unsuccessful,  applications  of  weak  solutions  of  nitrate  of 
silver  or  of  salicylic  acid  may  be  used.  Cure  may  be  permanent,  but 
oftener  the  discoloration  returns. 

Glossitis.^ — This  is  uncommon  in  early  life  except  as  a  result  of 
injury  of  some  sort.  The  edges  of  the  tongue  may  be  irritated  by  cari- 
ous teeth,  or  the  dorsum  by  corrosive  or  hot  fluids.  The  stings  of  insects 
are  an  occasional  cause.  Rarely  urticaria  may  involve  the  tongue. 
The  inflamed  portion  is  painful  and  deep-red,  with  prominent  papillae. 
In  severe  cases  the  whole  tongue  may  be  badly  swollen  and  there  is  sali- 
vation, moderate  fever,  and  difficulty  in  swallowing  and  in  speaking. 
The  swelling  may  be  so  considerable  that  the  tongue  protrudes  beyond 
the  lips,  and  even  breathing  may  be  interfered  with.  The  condition  is 
not  usually  serious.  The  course  is  slow,  the  swelling  subsiding  in  a  few 
days  and  leaving  superficial  ulceration  in  the  severer  cases.  Very  rarely 
a  parenchymatous  inflammation  of  the  tongue  occurs,  with  the  formation 
of  an  abscess  in  the  body  of  the  organ.  The  treatment  of  glossitis  con- 
sists in  purgation,  frequently  repeated  introduction  of  ice  into  the  mouth, 
and,  in  bad  cases,  scarification.  The  food  should  be  liquid,  given  through 
a  nasal  tube  if  necessary. 

Tongue=swa!Iowing. — This  rare  condition  is  occasionally  seen  in 
infants  who  are  suffering  from  nasal  obstruction.  Attention  was  first 
called  to  it  by  Bouchut.^  The  efforts  of  the  child  to  breathe  cause  a 
drawing  backward  of  the  body  and  tip  of  the  tongue  until  thej^  are 
pressed  against  the  hard  palate,  cutting  off  more  or  less  completely  the 
entrance  of  air.  Treatment  consists  in  drawing  the  tongue  forward  and 
maintaining  it  in  this  position.  At  the  same  time  efforts  must  be  made 
to  open  up  the  nasal  passages. 

Geographical  Tongue.^ — Epithelial  desquamation  of  the  tongue, 
wandering  rash  of  the  tongue,  lichenoid  of  the  tongue,  ringworm  of  the 
tongue,  and  various  other  titles  have  been  applied  to  this  common  dis- 
order, many  of  them  showing  our  lack  of  complete  knowledge  of  its 
nature. 

Etiology. — The  cause  is  uncertain.  Although  oftenest  seen  in  child- 
hood, it  is  frequent,  too,  in  infancy  and  sometimes  continues  into  adult 
life.  It  has  been  supposed  to  be  syphilitic,  scrofulous,  or  parasitic,  but 
without  good  reason.  It  certainly  often  occurs  in  subjects  suffering  from 
chronic  intestinal  indigestion  or  the  exudative  diathesis,  l)ut  by  no  means 
only  in  these.     H^'gienic  conditions  appear  to  have  no  positive  influence. 

Symptoras.^ — The  lesion  begins  as  a  small,  greyish-white  spot  on  the 
surface  of  the  tongue.  The  patch  enlarges  lapidly  and  irregularly,  while 
simultaneously  the  white  color  disappears  from  the  central  portion, 
leaving  a  bright-red  hue,  due  to  the  loss  of  epithelium  and  of  the  filiform 
papilhe.  The  slightly  i-aised  gi-ey  border,  consisting  of  epitlieUai  thicken- 
ing, advances  rapidly  over  different  parts  of  the  tongue,  the  outline  chang- 
ing daily.  Meanwhile,  although  the  region  immediately  within  the  bor- 
der is  still  bright-red  and  denuded  of  epithelium,  the  central,  older  portion 
of  the  lesion  gradually  assumes  the  normal  smooth,  glistening  appear- 
ance of  the  healthy  tongue,  through  the  development  of  new  epithelium 
upon  it.     The  in-egular  l)or(ler  gives  to  the  condition  the  title  "geograpli- 

1  Muladit's  dos  nouveau-n6s,  1885,  Stii  I'.il.,  27'.). 


668 


THE  DISEASES  OF  CHILDREN 


ical  tongue"  (Fig.  232)  from  the  siinilarit}'  to  the  outHne  of  a  map, 
while  the  term  "wandering  rash"  indicates  the  characteristic  constantly 
changing  appearance  and  position.  Several  patches  are  usually  present 
at  one  time,  often  partially  fusing  into  each  other,  and  new  ones  may 
form  as  the  older  disappear,  and  perhaps  spread  again  over  the  regions 
first  attacked. 

There  are  no  subjective  S3aiiptoms  produced  by  the  lesions,  and  the 
disease  is  entirely  harmless.  The  individual  patches  persist  about  a 
week,  but  the  course  as  a  whole  is  essentially  chronic,  lasting  sometimes 
months  or  years.     No  treatment  is  needed,  nor  is  any  effective. 

DISEASES  OF  THE  SALIVARY  GLANDS 

Malformations  of  the  salivary  glands  are  of  very  uncommon 
occurrence,  among  them  being  a  defective  formation  and  a  congenital 
salivary  fistula.     Tumors  are  rarely  encountered.     Concretions  may  rarely 


Fig.    233. — Bilateral    Secondary    Suppurative    Parotitis    after    Typhoid    Fever. 
Case   in    a    boy    of    11    years,   in   the   Children's   Ward  of   the   University   Hospital, 
Philadelphia. 

be  found  in  any  of  the  salivary  ducts,  or,  less  often,  in  the  glands  them- 
selves. Neuhof  ^  could  collect  but  7  instances  of  the  disease  in  children,  to 
which  he  added  3  others.  A  primary  purulent  sialo-adenitis  of  the  sub- 
maxillary or  sublingual  glands  is  occasionally  seen  in  the  first  weeks  or 
months  of  life  (Mikulicz  and  Kiimmell).^  The  parotids  are  not  involved. 
There  is  swelling  of  the  glands,  febrile  symptoms  develop,  and  pus  is 
discharged  through  the  ducts.  Often  distinct  abscess-formation  occurs. 
The  prognosis  is  usually  good. 

Ranula. — The   title   is  employed  to  designate  a  cystic  formation 
in  the  mucous  glands  or  the  sublingual  salivary  glands.     It  is  only  rarely 

1  Amer.  Journ.  Dis.  Child.,  1916,  XI,  232. 

2  Die  Krankh.  d.  Mundes,  1898,  228. 


Fig.  232. — Geographical  Tongue. 
ShowiriK  the  denuded  areas  with  elevated,  thickened  margins. 


DISEASES  OF   THE  SALIVARY  GLANDS  669 

found  in  early  life,  but  may  even  be  congenital,  and  8  such  cases  were 
collected  by  Le  Guay.^  If  of  considerable  size,  the  tongue  is  pressed 
upward  and  may  interfere  with  sucking. 

Secondary  Parotitis. — The  primarj^  form  of  parotitis  has  already 
been  considered.  (See  Mumps,  p.  494.)  Secondary  parotitis  is  sometimes 
seen  even  in  early  infancy.  It  may  occur  after  stomatitis  or  purulent 
otitis;  or  in  a  worse  form,  usually  advancing  to  suppuration,  it  may  com- 
plicate severe  fevers,  especially  typhoid  fever  and  septic  infection  (Fig. 
233).  The  germs  enter  through  the  duct  of  Steno,  or  by  way  of  the 
blood  vessels  in  metastatic  cases.  The  process  is  generallj'  unilateral. 
The  symptoms  are  the  usual  ones  of  inflammation,  combined  with  local 
pain,  swelling,  and  tenderness.  After  several  days  resolution  begins  in 
favorable  cases;  but  not  infrequently  there  is  deep-seated  suppuration 
with  increase  of  swelling  and  tenderness,  discoloration  appears,  and  finally 
pus  is  discharged  through  the  overlying  skin,  or  into  the  mouth  either 
through  the  duct  or  the  tissues  of  the  face.  Necrosis  of  the  jaw  or  severe 
hemorrhage  may  occur;  or  sometimes  death  take  place  from  sepsis.  In 
the  line  of  treaimeni  cold  compresses  should  be  applied  and  a  purgative 
given.  If  resolution  does  not  promptly  occur,  surgical  aid  should  be 
sought  before  fluctuation  develops. 

Mil<ulicz's  Disease.^ — This  is  a  very  uncommon  affection  of  which 
Tileston-  could  find  but  12  reported  cases  occurring  in  children.  It 
was  first  described  b}^  Mikulicz^  in  1892,  and  consisted,  according  to 
him,  of  a  bilateral,  painless  enlargement  of  the  salivary  and  lachrymal 
glands.  Some  cases  reported  after  his  pubHcations  have  been  associated 
with  changes  in  the  blood  suggesting  pseudoleukemia  or  leukemia,  and 
with  decided  enlargement  of  the  lymph-nodes  and  spleen.  These  cases 
should  probably  be  excluded.  There  may,  however,  be  a  moderate 
enlargement  of  the  lymph-nodes  and  of  the  spleen  present.  The  etiology 
is  obscure.  Mikulicz  considered  the  condition  the  result  of  the  action 
of  some  one  or  several  unknown  infectious  agents.  Tuberculosis  would 
seem  to  have  been  the  cause  in  some  instances.  The  histological  changes 
are  those  of  lymphoma  or  of  chronic  inflammation.  There  are  practically 
no  symptoms  except  the  bilateral  enlargement  mentioned,  and  perhaps 
a  disturbance  of  the  functions  of  the  glands,  resulting  in  dryness  of  the 
mouth  and  the  absence  of  tears.  Evidences  of  inflammation  are  wanting. 
The  course  is  slow,  but  the  prognosis  fairly  good  in  cases  uncomplicated 
by  serious  changes  in  the  blood.  In  the  line  of  treatment  arsenic  or  the 
iodides  may  be  given.  The  employment  of  the  Rontgen-ray  or  exci- 
sion may  be  needed  in  cases  not  yielding  to  medical  treatment. 

Salivation. — An  unusually  free  flow  of  saliva,  or  at  least  an  ina- 
bility to  retain  it  in  the  mouth,  is  seen  in  infants  of  3  or  4  months  at  the 
time  the  secretion  is  normally  fully  established.  After  this  period  in- 
creased flow  may  depend  upon  a  variety  of  causes,  especially  stonuititis 
of  any  form  and  particularly  that  produced  by  the  administration  of 
mercury;  or  may  be  caused  l)y  reflex  influences,  such  as  nausea  or  gas- 
tralgia ;  or  may  be  a  symptom  of  certain  nervous  affections.  The  duiation 
and  prognosis  depend  upon  the  cause,  and  treatment  is  to  be  directed  to 
this. 

iThftsede  Paris,  1911. 

2  Tnvns.  Aiiicr.  IVd.  Soc.  1911,  XXIII,  356. 

'  BoitriiKe  z.  Cliirurjiic,  Billrotli's  Festschrift,  1S92,  010. 


670  THE  DISEASES  OF  CHILDREN 


CHAPTER  II 


DISEASES  OF  THE  PHARYNX  AND  PALATE 
DEFORMITIES  AND  NEW  GROWTHS  OF  THE  PHARYNX  AND  PALATE 

Syphilitic  ulceration  may  take  place  in  the  pharynx,  oftenest  in  the 
palate.  Tuberculosis  of  the  pharynx,  not  including  the  tonsils,  is  of  very 
infrequent  occurrence,  and  especially  so  in  early  life.  Stenosis  may  be  a 
congenital  deformity,  or  result  from  syphilis  or  trauma.  Morbid  growths 
are  uncommon,  those  oftenest  seen  being  lymphoma  and  fibroma. 
Congenital  perforation  of  the  palate  may  occasionally  be  observed. 
If  developing  later,  it  is  oftenest  the  result  of  hereditary  syphilis.  A 
high  and  narrow  arch  to  the  palate  may  attend  the  presence  of  adenoid 
growths,  or  may  occur  independently  of  this  and  be  the  cause  of  some 
of  the  symptoms  usually  attributed  to  the  vegetations  (Landsberger).^ 
It  sometimes  accompanies  mental  defect. 


Fig.  234. — Cleft  Palate  with  Double  Harelip. 
Courtesy  of  Dr.  H .  R.  Wharton. 

Cleft  Palate. — -This  common  condition  consists  of  a  congenital 
fissure  of  the  palate,  oftenest  of  the  soft  palate  only  but  not  in- 
frequently of  the  bony  portion  as  well,  in  bad  cases  extending  into  a 
corresponding  fissure  in  the  lip.  In  the  worst  cases  the  palate  exhibits 
a  double  cleft  connecting  with  a  double  hare-lip,  and  leaving  the  inter- 
maxillary process  completely  separated  from  the  jaw  on  each  side  (Fig. 
234).  An  opening  through  the  palate  necessarily  interferes  with  sucking, 
since  the  abnormal  passage  into  the  nose  prevents  the  formation  of  the 
necessary  vacuum.  As  a  consequence  the  nutrition  of  the  infant  is 
severely  affected  and  special  methods  of  feeding  are  necessary.  A  long, 
large,  rubber  nipple  attached  to  a  glass  tube  and  rubber  bulb,  as  in  the 
Breck  Feeder  for  premature  infants  (p.  256,  Fig.  45)  is  often  of  service; 

1  Arch.  f.  Kinderh.,  191.5,  LXV,  113. 


ACUTE  CATARRHAL  PHARYNGITIS  671 

or  a  nipple  may  be  employed  to  the  upper  side  of  which  a  flap  of  thin 
rubber  is  attached  in  order  to  close  the  gap  in  the  palate  when  the  infant 
sucks.  In  other  cases  feeding  by  gavage  is  necessary.  In  spite  of  all  care 
severe  cases  generally  die,  not  so  much  from  lack  of  food,  as  on  account 
of  the  attending  constitutional  debility  usually  present.  If  the  child 
survive,  operation  is  best  deferred  until  the  2d  year  or  later. 

Paralysis  of  the  Palate  and  Uvula. — This  is  seen  especially  in 
diphtheria,  but  may  occasionally  develop  in  the  course  of  other  infectious 
diseases,  and  in  certain  disorders  of  the  nervous  system. 

Bifid  Uvula. — The  uvula  may  be  split  into  two  portions  at  its  tip, 
or  the  division  of  the  two  halves  may  extend  throughout  the  length, 
producing  a  double  uvula.     There  are  usually  no  sj-mptoms  present. 

ACUTE  CATARRHAL  PHARYNGITIS 
(Simple  Angina) 

Distinction  is  to  be  made  in  etiology  between  the  very  frequent  acute 
pharyngitis  occurring  as  a  primary  affection,  and  that  seen  in  the  course 
of  many  of  the  infectious  diseases,  especially  diphtheria,  scarlet  fever, 
rubella,  grippe,  and  often  measles,  or  accompanying  some  form  of 
stomatitis.  Acute  catarrhal  tonsillitis  is  to  be  viewed  as  often  a  part  of 
this  disease  and  may  be  discussed  in  this  connection.  The  symptoms 
of  primary  and  of  secondary  pharyngitis  are  largely  the  same,  and  any 
differences  will  be  considered  with  the  separate  diseases  with  which 
secondary  pharyngitis  is  associated.  The  primary  affection  alone  will 
be  considered  here. 

Etiology. — Pharyngitis  is  exceedingly  common  at  all  ages,  although 
infants  in  the  1st  year,  and  especially  in  the  first  6  months  of  life  are 
probably  less  predisposed  than  later.  Exposure  to  cold  and  wet,  dwell- 
ing in  overheated  rooms  with  subsequent  local  chilling  from  drafts, 
debilitated  health,  nasopharyngeal  obstruction,  and  similar  causes  pro- 
duce a  susceptibility,  and  are  certainly  common  etiological  factors. 
Digestive  diseases  not  infrequently  are  attended  by  irritation  of  the 
pharynx.  There  is,  too,  a  remarkable  predisposition  in  certain  individu- 
als or  families,  in  some  instances  dependent  upon  a  tendency  to  rheu- 
matic manifestations.  The  action  of  irritant  substances,  such  as  hot 
or  caustic  liquids,  is  an  occasional  factor.  All  the  conditions  mentioned 
act  as  predisposing  causes,  rendering  the  tissues  subject  to  an  invasion 
by  pyogenic  germs  from  the  mouth.  No  one  germ,  however,  appears[to 
be  specific. 

Symptoms. — The  disease  begins  acutely,  often  with  slight  fever 
and  malaise  and  accompanied  by  the  symptoms  of  acute  rhinitis  and 
laryngitis.  All  four  regions  may  be  involved  simultaneousl3^  or  not 
infrequently  the  pharynx  is  first  attacked  and  the  nose,  larynx  and  trachea 
later.  There  is  an  uncomfortable  sensation  in  the  throat,  whicli  varies 
from  that  of  slight  roughness  or  dryness  to  severe  pain  especially  on  swal- 
lowing. The  inflammation  often  produces  a  frequent,  annoying  cough. 
In  well-marked  cases  decided  fever  is  present,  with  chilliness,  malaise 
and  sometimes  headache.  These  are  most  marked  when  the  tonsils  are 
especially  involved.  The  submaxillary  lymphatic  glands  may  be  some- 
what swollen,  and  there  may  be  stiffness  and  aching  in  the  neck.  In 
infants  and  young  children  the  onset  is  sometimes  quite  severe,  with 
vomiting,  high  fever  and  perhaps  convulsions,  and  the  patients  look 
quite  ill,  although  at  this  age  they  often  cannot  or  do  not  make  complaint 


672  THE  DISEASES  OF  CHILDREN 

of  trouble  in  the  throat.  In  fact,  it  is  only  in  older  children  that  any 
dependence  can  be  placed  upon  the  statements  regarding  the  sensations 
in  this  region.  At  times  a  gulping  method  of  swallowing  or  a  refusal  to 
take  food  may  be  a  suggestive  indication.  The  speech  is  frequently 
affected,  enunciation  being  interfered  with  by  the  pain  which  the  effort 
evokes. 

The  local  appearance  consists  of  deep  redness  and  more  or  less  swelling 
of  the  pharynx,  soft  palate,  uvula,  tonsils  and  pillars.  The  mucous 
membrane  is  at  first  dry;  later  covered  with  thick,  tenacious  mucus 
especially  on  the  posterior  pharyngeal  wall.  All  these  tissues  may  be 
involved  or  only  some  of  them,  and  to  a  varjdng  degree.  The  mild 
cases  exhibit  onlj^  a  slight,  bright-redness;  the  severe  ones  a  deep-red 
color  with  swelling.  In  some  severe  cases  there  is  little  swelling,  but  the 
redness  and  the  pain  are  very  prominent  features. 

Course  and  Prognosis. — The  course  of  the  attack  is  usually  short, 
complete  recovery,  under  treatment,  occurring  in  from  3  to  4  days  or  even 
sooner.  Not  infrequently,  however,  if  rhinitis  and  laryngitis  are  not 
present  at  the  onset,  these  develop  later  and  the  process  then  extends 
downward  to  the  trachea  and  bronchi;  or  the  pharyngeal  process  may 
be  slow  in  recovery  or  show  a  tendency  to  frequent  relapses.  The 
association  of  follicular  tonsillitis  with  catarrhal  pharyngitis  is  very 
common. 

Diagnosis. — This  consists  mainly  in  determining  whether  the 
condition  is  a  primary  one,  or  is  dependent  upon  some  febrile  or  other 
disease.  Scarlet  fever  often  exhibits  sore  throat  as  its  first  symptom, 
and  the  diagnosis  must  be  reserved  until  later  and  catarrhal  diphtheria 
may  cause  confusion.  In  both  disorders  a  history  of  exposure  to 
infection  is  sometimes  of  aid,  and  in  the  latter  a  bacteriological  ex- 
amination will  settle  the  question.  The  pharyngitis  of  grippe  can  be 
distinguished  onlj^  by  the  prevalence  of  other  symptoms  of  the  disease 
in  epidemic  form. 

Treatment. — ^Prophylaxis  is  important  in  those  especially  pre- 
disposed. Judicious  hardening  should  be  employed  through  the  use  of 
general  cool  morning  bathing  or  local  cold  bathing  of  the  throat;  life  more 
in  the  open  air;  avoidance  of  hot,  close  rooms;  and  similar  hygienic  meas- 
ures. For  the  treatment  of  the  attacks  a  saline  purgative  may  be  admin- 
istered at  the  beginning,  a  hot  general  bath  or  a  mustard  foot-bath  given, 
and  the  child  then  confined  to  bed  and  well  covered  to  induce  free  per- 
spiration. Older  children  may  in  addition  be  given  a  bowl  of  cracked  ice 
with  instructions  to  allow  the  pieces  to  melt  as  far  back  in  the  throat  as 
possible.  A  diaphoretic  fever-mixture  containing  aconite  and  potassium 
citrate  is  of  service,  or  if  there  is  much  pain  small  doses  of  antipyrine  or 
phenacetin.  Gargles  of  normal  saline  solution  or  of  tannic  acid,  such  as 
infusion  of  rhus  glabra,  are  very  popular  and  serviceable  remedies  in  chil- 
dren old  enough  to  use  them.  Lozenges  containing  menthol,  or  an  oily 
spray  of  the  same  (menthol  gr.  2  (0.13);  petrolatum  licj.  fi.oz.  1  (30))  often 
give  much  relief.  Other  lozenges  containing  eucalyptus,  krameria,  or 
guaiac  are  serviceable.  Lime-drops  are  often  useful  and  agreeable  to  the 
child.  Inhalation  of  watery  vapor  with  benzoin  is  of  value  if  there  is  much 
pain.  Cold  compresses  to  the  throat  are  sometimes  very  useful.  In  the 
latter  stages,  and  sometimes  even  from  the  onset,  painting  the  throat  with 
glycerine  of  tannic  acid  gives  great  relief  and  hastens  recovery,  although 
in  some  instances  it  is  irritating.  In  other  cases  a  25  per  cent,  solution 
of  argyrol  maj'  be  employed  with  benefit. 


CHRONIC  PHARYNGITIS  673 

CHRONIC  PHARYNGITIS 

This  is  a  condition  less  often  seen  in  children  than  in  adults,  yet  not 
uncommon.  It  may  follow  chronic  digestive  disorders  or  repeated  attacks 
of  acute  pharyngitis,  but  its  more  frequent  cause  is  obstruction  to  respira- 
tion through  the  nose.  Involvement  of  the  base  of  the  tongue  and  of  the 
tonsils  may  occur  as  complications.  The  symptoms  consist  of  slight 
discomfort  in  the  throat  and  efforts  to  clear  it,  together  with  an  irritating 
cough,  sometimes  moderate  and  almost  continuous,  sometimes  severe 
and  occurring  paroxysmally  and  only  at  certain  periods,  and  brought  on 
by  the  mucus  descending  toward  the  larjmx.  The  cough  is  often  falsely 
assigned  to  bronchitis.  Inspection  of  the  throat  shows  enlarged,  promi- 
nent red  or  yellowish  distended  follicles  dotted  especially  upon  the  pos- 
terior wall  of  the  pharjmx,  with  the  surrounding  mucous  membrane  more 
or  less  inflamed,  or  of  a  pale  color  and  often  partly  covered  by  muco- 
purulent secretion.  The  vessels  may  be  visibly  dilated.  There  is  no 
fever  and  no  actual  pain,  unless  exacerbations  occur.  Deafness  may  de- 
velop as  a  complication,  but  this  is  dependent  rather  upon  accompanying 
adenoid  growths  of  the  nasopharynx.  In  advanced  cases  atrophy  of 
the  mucous  membrane  of  the  pharynx  develops.  The  course  is  chronic 
and  the  disease  yields  slowly  even  under  treatment. 

Treatment  consists  in  removing  any  nasal  obstruction  or  affection  of 
the  tonsillar  tissues;  attending  to  the  state  of  the  digestive  apparatus;  and 
the  avoidance  of  all  irritation  b}^  exposure  and  the  like.  General  tonic 
remedies  and  change  of  air  are  also  often  necessary.  In  addition,  local 
treatment  is  required  consisting  in  the  use  of  alkaline  sprays,  if  there  is 
much  irritation,  and  the  cauterization  of  the  individual  follicles  if  not  too 
numerous. 

Uvulitis. — Inflammation  of  the  uvula  occurs  often  as  one  of  the 
symptoms  of  acute  pharyngitis,  although  occasionally  it  is  largely  localized 
in  the  uvula.  In  some  cases  it  may  be  the  direct  result  of  trauma. 
There  is  swelling  and  redness  of  the  part,  generally  with  edema  and  pain 
on  swallowing;  and  if  elongation  is  present  and  the  uvula  comes  into 
contact  with  the  base  of  the  tongue  there  is  a  harassing,  tickling  cough. 
Applications  of  glycerin  of  tannic  acid,  a  weak  solution  of  nitrate  of 
silver,  or  of  epinephrine  (1 :  1000)  are  of  advantage,  as  is  the  sucking 
of  ice.     In  bad  cases  scarification  of  the  uvula  may  be  required. 

Edema  of  the  Uvula. — This  is  a  condition  frequently  attendant 
upon  uvulitis.  In  addition  to  this,  edema  may  occur  in  nephritis  and 
in  hydremic  states.  The  local  treatment  is  similar  to  that  required  for 
uvulitis.  Remedies  directed  to  any  more  general  cause  may  also  be 
needed. 

Elongated  Uvula. — With  acute  or  chronic  pharyngitis,  or  inde- 
pendently of  these  and  perhaps  of  congenital  origin,  some  degree  of 
elongation  of  the  uvula  may  be  observed.  The  condition  depends  upon 
inflammation  in  the  acute  cases,  and  upon  relaxation,  or  an  unusual 
thickening  of  the  mucous  membrane  in  those  following  a  chronic  inflamma- 
tion. There  is  no  sensation  of  sore  throat  exporionced  unU'ss  pharyngitis 
is  also  present,  the  only  symptoms  being  an  annoying,  tickhng  cougli  and 
a  desire  to  clear  the  throat,  worse  especially  when  lying  down  at  night, 
and  produced  by  the  uvula  coming  into  contact  witii  tlie  base  of  the 
tongue.  The  cough  may  i)e  .so  severe  that  vomiting  results.  Examina- 
tion of  the  fauces  discovers  the  uvula  touching  the  tongue  if  tlic  breatii 
is  held  or  air  is  expired  through  the  nose.    Troi'.tment  consists  in  measures 

43 


674  THE  DISEASES  OF  CHILDREN 

for  diminishing  the  size  of  the  uvula.  If  the  condition  is  due  to  inflamma- 
tion or  relaxation,  the  application  of  astringent  solutions,  such  as  glycerine 
of  tannic  acid,  or  of  adrenaline,  is  often  promptly  efficacious.  Astringent 
lozenges,  as  of  eucah-ptus,  are  also  of  service.  In  obstinate  cases  de- 
pendent upon  a  congenital  relaxation  or  upon  chronic  thickening  amputa- 
tion of  the  tip  of  the  uvula  may  be  required,  but  other  treatment  should 
first  be  given  through  trial. 

PSEUDOMEMBRANOUS  PHARYNGITIS 
(Septic  Sore  Throat;  Pseudodiphtheria ) 

Etiology. — These  titles  are  but  some  of  those  applied  to  different 
groups  which  appear  to  constitute  varieties  of  one  disorder.  Pseudo- 
membranous tonsillitis  is  included  in  this  description.  The  disease  may 
be  primary,  or  be  secondary  to  some  other  affection,  especially  the  acute 
exanthemata,  such  as  measles  and,  most  of  all,  scarlet  fever;  although 
often  seen,  too,  in  typhoid  fever.  In  many  of  these  the  disease  may 
closely  resemble  diphtheria.  As  a  primary  affection  it  may  occur  without 
the  previous  existence  of  any  of  the  acute  infections.  Thus  in  a  very 
severe  form  accompanied  by  extensive  necrosis  it  may  occasionally  be 
seen  in  the  new  born  (Epstein),^  and  in  these  cases  it  perhaps  complicates 
Bednar's  aphthae  produced  by  injury  to  the  mucous  membrane  through 
rough,  unskillful  washing  of  the  mouth  and  throat,  or  may  be  consecu- 
tive to  and  associated  with  thrush.  In  the  form  frequently  designated 
" septic  sore  throat"  it  has  often  appeared  epidemically.  A  number  of  such 
instances  have  been  described  in  Europe,  Savage-  having  collected  and 
reviewed  18  English  epidemics.  In  1911  to  1913  several  large  local  out- 
breaks occurred  in  the  United  States,  notably  in  Boston  and  Baltimore 
(Ruhrah),^  and  in  parts  of  New  York  State  (Bigg)^  and  elsewhere,  the 
largest  being  an  extensive  epidemic  affecting  over  10,000  persons  in 
Chicago  (Capps  and  Miller). '^  In  several  such  epidemics  the  disease  has 
been  traced  directly  to  the  milk  supply. 

The  primary  source  of  the  affection  in  whatever  form  it  manifests 
itself  is  undoubtedly  microbic.  The  germ  is  much  most  frequently  the 
streptococcus  pyogenes,  sometimes  associated  with  the  staphylococcus 
aureus  or  albus.  At  times  the  staphylococcus  alone  is  found,  and  the 
pneumococcus  and  other  germs  are  occasionally  observed.  The  influenza 
bacillus  appears  to  be  the  agent  in  some  instances;  the  diphtheria  bacillus 
is  never  present.  The  relationship  of  the  pseudodiphtheria  bacillus  to 
pseudomembranous  inflammation  is  not  yet  definitely  settled.  The 
epidemic  outbreak  would  indicate  that  the  disease  is  transmissible  both 
indirectly,  as  by  milk,  and  perhaps  by  direct  contact. 

Pathological  Anatomy. — The  mucous  membrane  of  the  throat 
is  often  deep  red,  and  there  is  prone  to  develop  a  pseudomembrane, 
either  on  the  tonsils  alone  or  more  widely  spread.  In  structure  it  is 
practically  identical  with  that  of  diphtheria,  but  macroscopically  it  may 
differ  somewhat  from  this  in  being  more  friable,  softer,  and  more  easily 
removable.  The  process  shows  the  same  tendency  as  does  diphtheria  to 
involve  the  uvula,  the  pillars,  and  in  fact  all  the  neighboring  tissues;  and 
it  may  go  on  to  extensive  necrotic  destruction  or  even  to  gangrene. 

1  Jahrb.  f.  Kinderh.,  189.5,  XXXIX,  420. 

2  Milk  and  the  Public  Health,  1912.     Ref.,  Hamburger,  .Johns  Hopk.  Hosp.  Bull., 
1913,  XXIV,  1. 

3  Amer.  Journ.  Dis.  Child.,  1912,  IV,  .301. 

*  New  York  Med.  Rec,  1915,  LXXXVIII,  945. 
'  Journ.  Amer.  Med.  Assoc.,  1912,  LVIII,  1848. 


PSEUDOMEMBRANOUS  PHARYNGITIS  675 

The  germs  are  found  in  large  numbers  in  the  pseudomembrane  and  in  the 
underlying  mucous  membrane  and  neighboring  h'mphatic  glands,  and 
even  in  the  blood.  The  glands  in  the  neck  may  be  involved,  and  in  bad 
cases  other  organs  are  attacked  by  the  general  septic  process,  especially 
the  kidneys  and  the  lungs.  In  the  milder  cases  no  pseudomembrane 
develops,  or  it  is  superficial  and  separates  easily. 

Symptoms. — The  degree  of  local  and  constitutional  involvement 
varies  greath'.  In  the  primary  cases  of  the  epidemic  type  {septic  sore 
throat)  as  seen  in  the  United  States,  the  onset  is  generally  abrupt,  with 
chilliness,  fever,  headache,  vague  general  pains,  sometimes  nausea  and 
vomiting,  and  occasionally  a  convulsion.  A  diffuse  and  often  dusky 
redness  of  the  pharynx  and  pillars  appears,  and  in  a  few  hours  patches  of 
exudation  usually  develop  on  the  tonsils  or  pharynx,  which  can,  as  a  rule, 
be  wiped  off  without  difficulty.  In  2  or  3  days  the  glands  in  the  neck 
become  more  or  less  enlarged  and  tender,  but  rarely  suppurate.  Some 
cases  are  much  more  severe  and  exhibit  hyperpyrexia  and  great  glandular 
swelling;  and  there  are  instances  seen  during  epidemics  which  run  a 
malignant  course  and  are  fatal  wath  septic  symptoms  in  a  few  days. 
Islilder  cases  may  have  no  pseudomembrane,  but  exhibit  a  diffuse,  dusky 
redness  of  the  throat;  and  in  others  there  is  only  the  appearance  of  a 
lacunar  tonsillitis. 

In  primary  cases  not  epidemic  in  type,  and  in  many  of  the  secondary 
cases,  the  affection  is  generally  milder  and  is  limited  chiefly  to  the  tonsils. 
The  attack  may  first  appear  as  a  lacunar  tonsillitis,  and  only  later  develop 
more  the  pseudomembranous  form.  The  deposit  can  be  removed  with 
comparative  ease  and  with  little  damage  to  the  tissues.  The  tonsils 
and  pharynx  are  red  and  swollen.  The  onset  is  usually  sudden  and  often 
stormy,  with  high  fever,  headache,  generally  pain  in  the  throat  especially 
on  swallowing,  and  sometimes  vomiting.  The  enlargement  of  the  sub- 
maxillary lymphatic  glands  is  usually  only  slight  and  the  prostration 
much  less  than  in  diphtheria.  Not  infrequently,  however,  especially  in 
the  secondary  cases,  the  attack  may  be  much  more  severe  than  this. 
In  this  event  the  membrane  may  spread  very  extensively,  involving  the 
pharynx  and  nasopharynx,  the  nose,  and  even  exceptionally  the  larynx, 
exactly  as  in  some  cases  of  diphtheria;  the  glandular  swelling  is  often 
very  decided;  the  temperature  high;  the  pulse  weak;  prostration  great, 
and  the  child  is  apathetic,  delirious,  or  in  stupor.  There  is,  in  fact,  the 
evidence  of  a  toxic  state,  and  hemorrhagic  or  other  cutaneous  erupt ioDs 
may  be  present,  and  grave  and  even  fatal  septic  complications  may 
develop.  Some  of  the  cases  are  probably  instances  of  erysipelas  of  the 
throat. 

Complications  and  Sequels. — The  mildest  cases  show  practically 
none.  In  the  severe  ones  cervical  lymphadenitis  is  not  uncommon  and 
may  even  be  suppurative;  laryngitis  may  develop,  esjiecially  in  cases 
consecutive  to  measles;  rhinitis  and  otitis  are  seen  chiefly  in  cases  occurring 
after  scarlet  fever;  bronchitis,  septic  nephritis  and  bronchopneumonia 
are  not  unusual,  and  vomiting  and  diarrhea  may  occur.  Arthritis  has 
been  not  unconunon  in  the  epidemics  reported. 

Course  and  Prognosis. — The  prognosis  on  the  whole  is  favoral)le. 
The  duration  is  but  3  or  4  tlays  in  the  milder  cases,  and  recovery  is  rapid. 
In  the  severer  forms  the  course  is  longer,  lasting  perliMps  1  to  2  weeks  and 
the  result  uncertain,  the  process  extending  both  into  tlie  substance  of  the 
tonsils  and  to  other  regions.  Extensive^  sloughing  sometimes  takes  place, 
all  the  symptoms  of  sepsis  develop,  and   the  case  ends  fjitaliy.      I'oitu- 


676  THE  DISEASES  OF  CHILDREN 

nately  this  outcome  is  uncommon  in  the  primary  cases,  although  oftener 
seen  in  those  secondary  to  other  diseases.  Occurring  in  early  infancy  in 
debilitated  subjects  the  disease  is  usually  fatal. 

Diagnosis. — The  affection  causing  most  difficulty  in  diagnosis  is 
diphtheria.  In  average  cases  of  pseudomembranous  pharyngitis  the 
onset  is  more  sudden  and  stormy  than  in  diphtheria,  and  the  deposit  is 
oftener  limited  to  the  tonsils  and  is  not  so  closely  adherent.  There  is 
less  swelling  of  the  cervical  glands  and  less  prostration  of  the  system, 
except  in  some  of  the  severe  cases  of  epidemic  septic  sore  throat.  The 
extension  of  membrane  beyond  the  tonsils  is  a  strong  evidence  that  the 
disease  is  diphtheria.  There  are,  however,  so  many  exceptions  to  these 
distinctions  that  dependence  should  be  placed  only  upon  bacteriological 
examination.  The  milder  primary  cases  without  pseudomembrane  do 
not  present  the  same  diagnostic  difficulties.  The  secondary  cases  are 
usually  more  easy  of  recognition,  owing  to  the  presence  of  other  diseases 
such  as  measles  or  scarlet  fever;  but  here,  too,  a  positive  diagnosis  can  be 
made  only  by  bacteriological  study. 

Treatment. — ^Cases  of  this  disorder  should  be  isolated  as  in  lacunar 
tonsillitis.  While  waiting  for  the  result  of  bacteriological  examination  the 
patient  should  be  given  the  benefit  of  the  doubt  and  receive  diphtheria- 
antitoxin.  In  the  severe  cases  vigorous  local  treatment  may  be  required, 
yet  not  at  the  expense  of  the  patient's  strength.  In  general,  this  is 
similar  to  that  described  for  anginose  scarlatina  and  consists  of  syring- 
ing or  spraying  the  throat  and  nose  with  warm  alkaline  solutions 
or  normal  salt  solution;  the  use  of  antiseptic  and  astringent  gargles, 
or  the  application  to  the  throat  of  diluted  peroxid  of  hydrogen  (1:4) 
followed  by  astringents,  such  as  tincture  of  the  chloride  of  iron  (1:4), 
glycerine  of  tannic  acid,  or  nitrate  of  silver  (5  to  10  per  cent.).  An  ice- 
bag  should  be  applied  externally  and  the  general  strength  maintained  by 
tonic  and  stimulant  remedies. 

RETROPHARYNGEAL  ABSCESS 

This  disease,  although  not  common  as  compared  with  other  affections 
of  the  pharynx,  is  seen  not  infrequently  in  the  practice  of  those  having 
to  do  with  many  sick  children.  Bokai^  states  that  in  438,799  sick  children 
in  the  Children's  Hospital  in  Budapest  in  49  years  there  were  926  cases 
of  retropharyngeal  adenitis  or  abscess.  Retropharyngeal  adenitis 
not  advancing  to  suppuration  and  without  clinical  syfnptoms  is  probably 
not  at  all  an  uncommon  affection. 

Etiology .^ — ^Age  is  a  factor  of  great  importance,  nearly  all  cases 
occurring  in  the  first  3  years  of  life  (Bokai),  and  especially  in  infants  under 
1  year.  Only  when  the  abscess  is  secondary  to  caries  of  the  vertebrae 
is  it  more  likely  to  develop  after  the  period  of  infancy.  Catarrhal  con- 
ditions of  the  nasopharynx  commonly  precede  the  disease  and  are  the 
starting  point.  Consequently  abscess  is  seen  oftenest  in  the  colder 
season  of  the  year  when  catarrhal  states  are  most  common.  Exception- 
ally some  infectious  disorder,  as  scarlet  fever,  grippe,  or  measles,  is  the 
predisposing  cause.  A  debilitated  condition  of  health  is  also  a  factor 
of  importance,  although  children  in  previously  good  general  health  may 
be  attacked.     The  gemis  found  in  the  abscess  are  oftenest  streptococci. 

Pathological  Anatomy. — ^The  lesion  consists  usually  of  an  in- 
flammation developing  in  the  retropharyngeal  lymphatic  glands.  The 
process  is  exactly  similar  to  that  of  lymphadenitis  elsewhere.     The  glands 

iTrait6  des  mal.  do  reiifance,  Granchev,  1904,  11,70. 


RETROPHARYNGEAL  ABSCESS 


677 


may  produce  a  prominent  swelling  in  the  pharj-nx  without  the  produc- 
tion of  pus,  but  oftener  suppuration  takes  place.  The  swelling  is  usually 
localized  more  upon  one  side  or  the  other,  inasmuch  as  the  glands  are 
situated  upon  each  side  of  the  median  line.  In  the  much  less  common 
cases  in  which  the  process  is  secondary  to  caries  of  the  cervical  vertebrse, 
the  pus  may  sometimes  burrow  downward  along  the  spinal  column. 

Symptoms. — -The  first  suggestive  symptom  appearing  after  the 
development  of  fever  of  undiscovered  cause,  or  perhaps  attending  a  naso- 
pharyngeal catarrh,  is  difficulty  in  swallowing,  which  may  become  so 
decided  that  no  food  can  be  taken,  and  efforts  to  accomplish  it  are  fol- 
lowed by  regurgitation  through  the  mouth  or  nose.     Associated  with  this 


'Tfcw  |ay|3o|3/n  I  *  I  3  k  1^  I  fe  I'y  I  ?  I'y  kol//  |/x|/J  \/¥\/r\r6\/7 

Fig.    235. — Temimckaii  itK    (iiakt   fuo.m   a   Case   ok   Re  iitorjiAUVMiKAi.  Aiisce.-,.s   i.\  a 

Child  of  20  Months. 
(Hand,  Annula  of  Gynaec.  and  Pedial.,  lSf)<t,  XII.  Jan.) 

is  usually  an  interference  with  respiration  which  makes  it  of  a  vcmv  char- 
acteristic nature.  It  becomes,  namely,  a  spluttering  or  gurgling,  as 
though  there  were  an  accumulation  of  mucus  in  the  back  of  the  throat; 
but  there  is  usually  not  the  stridor  of  laryngeal  disease.  The  mouth  is 
kept  open  and  the  head  rigidly  thrown  backward  and  occasionally  to 
one  side.  Kespiration  through  tlic  nose  is  obstructed  and  there  is  snoring 
during  sleep.  Sometimes  in  advanced  cases  there  is  dysjmea  from  pres- 
sure of  the  abscess  on  the  larynx.  The  voice  is  nasal  but  usually  not 
hoarse.  Sligiit  cough  is  not  uncommon.  The  constitutional  symptoms 
may  be  inconsiderable,  but  debility  and  more  or  less  fever  are  the  rule 
(Fig.  235),  vomiting  and  loss  of  appetite  may  be  present,  and  sometimes 


678  THE  DISEASES  OF  CHILDREN 

prostration  is  decided.  In  all  cases  with  evident  symptoms  direct  ex- 
amination of  the  pharynx  reveals  sometimes  to  the  eye  and  always  to  the 
palpating  finger  a  fluctuating  mass  projecting  forward  from  the  postero- 
lateral pharyngeal  wall,  most  marked  on  one  side,  and  sometimes  extend- 
ing so  far  forward  that  the  pharynx  is  nearly  filled  and  the  uvula  is 
displaced  laterally.  The  mucous  membrane  of  the  pharynx  is  of  a  red 
color.  In  some  cases  the  swelling  is  visible  from  without,  upon  one 
side  of  the  neck  behind  and  below  the  angle  of  the  jaw  and  extending 
backward  and  downward.  This  may  be  dependent  either  upon  pus 
burrowing  in  this  direction,  or  upon  involvement  of  other  neighboring 
lymphatic  glands. 

Should  the  glandular  swelling  be  found  early  the  fluctuating  character 
is  absent  and  the  mass  is  merely  indurated  (Retropharyngeal  adenitis); 
but  usually  pus  has  been  formed  by  the  time  the  characteristic  symptoms 
appear.  In  abscess  in  older  children,  dependent  upon  caries,  the  onset 
is  more  insidious,  the  constitutional  symptoms  generally  less  marked,  and 
there  is  little  if  any  fever. 

Course  and  Prognosis. — Occasionally  enlargement  of  the  retro- 
pharyngeal glands  disappears  without  suppuration.  This  is  uncommon 
however,  in  patients  who  have  exhibited  cUnical  manifestations.  The 
course,  as  a  rule,  is  rapid,  and  in  from  a  few  days  to  a  week  the  condition 
becomes  apparently  a  most  threatening  one.  If  there  is  early  discovery 
of  it  and  prompt  surgical  interference,  the  prognosis  is  good  in  the  major- 
ity of  cases.  Sometimes,  however,  in  young  infants  the  constitutional 
depression  is  so  severe  that  death  occurs  even  though  the  abscess  has 
been  satisfactorily  opened.  In  other  cases  the  cavity  constantly  refills 
and  gradual  failure  of  strength  takes  place.  The  majority  of  deaths  occur 
in  subjects  in  whom  the  diagnosis  has  not  been  made.  Here  sudden 
death  may  follow  from  edema  of  the  glottis  or  pressure  upon  the  larynx, 
or  may  result  from  rupture  of  the  abscess  into  the  larynx  and  consequent 
asphyxia;  or,  escaping  asphyxia,  the  patient  may  later  die  from  a  septic 
aspiration-pneumonia.  Instances  of  erosion  of  blood  vessels  and  fatal 
hemorrhage  are  on  record.  In  other  cases  the  pus  may  burrow  out- 
wardly and  open  on  the  side  of  the  neck;  or,  more  unfavorably,  may 
pass  downward  into  the  mediastinum.  The  actual  death-rate  is,  how- 
ever, low;  scarcely  4  per  cent.,  according  to  the  statistics  of  Bokai.' 

When  the  abscess  depends  upon  cervical  caries  the  course  is  much 
slower  and  operation  is  prone  to  be  followed  by  a  reaccumulation  of  pus 
and  sometimes  by  final  exhaustion  of  the  patient.  There  is  also  a  greater 
tendency  to  burrow  in  different  directions,  but  less  danger  of  asphj^xia. 

Diagnosis. — This  is  very  misleading  to  those  who  have  not  en- 
countered the  disease;  easy,  however,  on  digital  palpation.  This  ex- 
amination is  very  important.  It  must  be  made  thoroughly,  with  the 
finger  guarded  against  biting  by  the  patient,  but  rapidly  in  order  not  to 
cause  interference  with  respiration.  Apart  from  the  results  of  palpation 
the  characteristic  symptoms  are  the  position  of  the  head,  the  open  mouth, 
the  spluttering  respiration  and  the  difficulty  in  swallowing.  Laryngeal 
stenosis  may  be  simulated  if  the  abscess  is  rather  deeply  situated  and 
presses  against  the  larynx.  The  history  of  the  case  and  the  presence  of 
other  symptoms  as  described  will  generally  remove  the  danger  of  mistake. 
Edema  of  the  ylottis  has  none  of  the  characteristic  symptoms  and  especialh' 
no  evidence  of  abscess  found  on  digital  examination.  Whether  the  ab- 
scess depends  upon  lymphadenitis  or  is  secondary  to  cervical  caries  can- 

1  Jahrb.  f.  Kinderh.,  1892,  XXXIII,  360, 


LACUXAR   TONSILLITIS  679 

not  always  be  determined.  In  the  latter  condition,  o^ever,  the  patients 
are  usually  older;  the  symptoms  come  on  much  more  slowly  with  previous 
ill  health ;  the  abscess  is  more  in  the  median  line :  and  there  is  more  likely  to 
be  swelling  visible  upon  the  side  of  the  neck  externally.  There  is  also 
greater  stiffness  of  the  neck  with  other  symptoms  of  involvement  of  the 
cervical  vertebrae. 

Treatment. — Surgical  intervention  should  be  practised  as  soon  as 
an  abscess  is  detected.  Except  in  cases  of  caries,  or  unless  the  glandular 
abscess  is  ah-eady  pointing  externally  in  the  neck,  incision  from  within 
the  mouth  is  greatly  to  be  preferred.  The  child  should  be  seated  in  an 
upright  position  and  firmh'  held  with  its  arms  pinioned;  a  bistoury 
wrapped  with  adhesive  plaster,  except  the  point,  introduced  along  the 
guiding  finger  placed  in  the  mouth;  incision  made,  and  the  child's  head 
rapidly  bent  forward  and  downward  to  prevent  the  entrance  of  pus  into 
the  larynx.  As  there  is  always  some  danger  of  the  pdges  of  the  clean- 
cut  wound  reuniting  and  the  abscess  refilling,  a  good  substitute  measure 
is  to  push  blunt-pointed  scissors  into  the  abscess  and  then  separate  the 
blades  and  withdraw  them  while  in  this  position.  Immediate  and  strik- 
ing relief  follows  the  operation  and  in  the  majority  of  cases  there  is  no 
further  trouble. 


CHAPTER  III 
DISEASES  OF  THE  TONSILLAR  TISSUE 

Tumors  of  the  Tonsillar  Tissue.^ — These  are  of  rare  occurrence, 
papilloma  and  fibroma  l)eing  those  oftenest  seen.  Lymphosarcoma  of  the 
faucial  tonsils  is  also  encountered.  Tuberculosis  of  the  tonsils  and  ade- 
noids, of  a  nature  discoverable  clinically,  is  of  rare  occurrence.  Patho- 
logically, tubercle  is  found  in  about  5  per  cent,  of  tonsils  examined.  (See 
Tuberculosis,  p.  557.) 

Acute  Catarrhal  Tonsillitis. — This  is  a  part  of  acute  catarrhal 
pharyngitis  and  its  sj^mptoms  do  not  differ  from  those  already  considered 
under  that  heading.  Pseudomembranous  tonsillitis  has  been  described  in 
discussing  Pseudo-membranous  Pharyngitis  (p.  674). 

ACUTE  LACUNAR  TONSILLITIS 
(Follicular  Tonsillitis) 

Although  quite  distinct  from  catarrhal  tonsillitis,  the  lacunar  form 
shades  into  it  in  many  cases,  one  or  more  small  engorged  lacuna  often 
appearing  in  the  catarrhal  variety  and  then  disappearing  quickly.  The 
more  typical  cases  are  here  described  in  which  the  inflammation  is  located 
chiefly  in  the  crypts  of  the  tonsils. 

Etiology.— The  disease  is  very  common  at  all  ages,  except  in  infancy 
and  especially  in  the  1st  year  of  life,  although  it  ma}^  occur  at  this  pcriocf. 
As  with  catarrhal  tonsillitis  exposure  to  cold  and  wet,  and  the  occurrence 
of  digestive  disturbances  are  not  infrequent  causes.  There  is  likewise  an 
undoubted  contagiousness  sometnnes  seen.  In  man}'  children  there  is 
a  remarkable  individual  predisposition,  and  in  them  attacks  arc  of  groat 
frequency.  Subjects  with  a  tendency  to  rheumatism  or  born  of  rheu- 
matic parents  are  very  susceptible  to  the  disorder.  In  fact,  inflanuiiation 
of  the  tonsils  or  pharynx  must  often  be  considered  as  one  of  the  manifesta- 
tions of  rheumatism.     (See  Rheumatism,  pp.  622,  626.)    The  presence  of 


680  THE  DISEASES  OF  CHILDREN 

chronic  tonsillar  hypertrophy  is  likewise  a  powerful  etiological  factor. 
Under  the  influence  of  such  predisposing  causes  bacteria  of  various  sorts, 
oftenest  staphylococci,  pneumococci  and  streptococci,  penetrate  into  the 
lacunae  and  induce  inflammation  there. 

As  a  secondary  affection,  lacunar  tonsillitis  is  especially  common  in 
the  course  of  scarlet  fever  and  diphtheria,  and  is  considered  under  these 
headings. 

Pathological  Anatomy. — The  process  consists  primarily  of  an 
inflammation  produced  by  the  action  of  the  invading  bacteria.  There 
results  an  inflammatory  swelling  of  the  lymph-follicles  of  the  tonsils, 
which  blocks  up  the  exit  of  the  lacunae  of  which  the  follicles  with  their 
epithelial  covering  form  the  walls.  The  proliferated  and  desquamated 
epithelial  cells,  Avith  lymphocytes  and  bacteria,  as  well  as  with  the  fibrin 
sometimes  produced  under  the  influence  of  the  inflammation,  are  thus 
retained  in  the  form  of  small,  whitish  or  yellowish  masses,  which  finally 
are  discharged  as  the  swelling  about  the  mouths  of  the  crypts  diminishes. 
With  this  process  is  combined  an  inflammatory  enlargement  of  the  whole 
tonsil,  and  often  more  or  less  general  pharyngitis.  The  exudate  may  dis- 
appear very  rapidly,  and  reappear  if  the  opening  of  the  crypt  is  again 
closed. 

Symptoms. — The  attack  begins  with  chilliness,  malaise,  pain  in 
the  head  and  body,  loss  of  appetite,  and  fever  which  quite  commonly 
reaches  103°  or  104°F.  (39.4°  or  40°C.)  or  over.  Vomiting  and  diarrhea 
sometimes  occur,  the  tongue  is  coated,  and  the  breath  heavy.  The 
throat  is  sore  and  swallowing  and  speaking  painful,  though  often  not  to 
such  a  degree  as  in  many  cases  of  catarrhal  tonsillitis,  and  small  chil- 
dren with  the  disease  may  maintain  that  they  have  no  pain  in  the  throat. 
Moderate  swelling  of  the  cervical  lymphatic  glands  may  be  present.  An 
erythematous  rash  may  sometimes  be  observed  and  lead  to  an  erroneous 
diagnosis  of  scarlet  fever. 

Examination  of  the  throat  shows  swollen,  deep-red  tonsils  with  few  or 
many  irregularly  shaped  yellowish-white  spots  of  varying  size.  The 
spots  differ  in  their  apparent  nearness  to  the  surface,  some  being  well 
within  the  cr3'^pts  of  the  tonsils  and  some  already  discharging.  Not  in- 
frequently, owing  to  the  close  apposition  of  the  lacunae  and  the  amount  of 
cheesy  secretion,  the  tonsil  seems  to  be  covered  by  a  uniform  deposit 
suggesting  a  diphtheritic  pseudomembrane.  In  such  cases,  however,  the 
secretion  can  be  more  or  less  completely  removed  by  gentle  rubbing  with 
a  cotton  swab,  without  any  bleeding  surface  remaining.  The  process  is 
usually  bilateral,  although  by  no  means  always  equally  or  simultaneously 
developed  on  the  two  sides. 

Course  and  Prognosis. — Although  the  general  and  local  symptoms 
are  usually  severe,  they  arc  of  short  duration,  lasting  a  few  days  up  to  a 
week  or  occasionally  longer.  Convalescence  is  rapid,  yet  relapses  may 
occur  when  recovery  seems  about  to  begin.  The  constitutional  symp- 
toms are  usually  over  before  the  local  ones  have  entirely  disappeared. 
The  disease  has  a  favorable  issue  in  the  vast  majority  of  cases,  but  not 
always  so,  at  least  as  regards  complications,  since  the  tonsil  while  in  its 
inflamed  condition  permits  ready  access  of  germs  into  the  system.  Car- 
diac complications  may  consequently  quickly  follow  tonsillitis,  or  rheu- 
matic arthritis  develop.  Acute  nephritis  occasionally  occurs  as  a  com- 
plication, as  does  septic  involvement,  especially  of  the  joints. 

Diagnosis. — In  cases  where  the  deposit  has  become  confluent 
lacunar  tonsillitis  may  readily  be  confounded  with  diphtheria.     The  fact 


LACUNAR  TONSILLITIS  681 

that  the  deposit  is  an  easily  removable  secretion  and  not  a  necrotic 
destruction  of  the  mucous  membrane  is  readih'  apparent  in  most 
cases.  In  many  instances,  however,  diphtheria  begins  as  a  lacunar 
inflammation  or  even  remains  so,  and  in  such  only  bacteriological  ex- 
amination can  settle  the  question.  (See  Diphtheria,  p.  451.)  The 
presence  of  membrane  upon  the  pillars  or  uvula  as  well  as  on  the  tonsils 
excludes  the  diagnosis  of  mere  lacunar  inflammation.  Scarlet  fever  ex- 
hibits lacunar  tonsillitis  often  upon  the  first  day  of  the  attack.  The 
presence  of  other  symptoms  of  this  disease  determines  its  nature  in  most 
cases.  Aphthous  itiflammaiion  may  develop  upon  the  tonsil,  but  has  no 
real  resemblance  to  lacunar  tonsillitis  and  is  accompanied  by  lesions  else- 
where in  the  mouth. 

Treatment. — Inasmuch  as  there  is  so  often  a  possibility  of  the 
tonsillitis  being  really  diphtheritic  the  patient  should  be  isolated  and  in 
doubtful  cases  a  culture  should  be  taken.  Even  if  diphtheria  be  proven 
to  be  absent,  continued  separation  of  the  patient  is  wise,  owing  to  the 
contagious  character  of  simple  lacunar  tonsillitis  sometimes  observed. 
The  patient  should  be  at  rest  in  bed  and  be  given  small  doses  of  antipyrine 
or  phenacetin  to  control  fever  and  relieve  pain.  The  diet  should  be  fluid 
or  semisolid.  When  there  is  suspicion  of  the  disease  being  rheumatic  in 
nature,  salicjdates  in  some  form  should  be  administered.  The  sucking 
of  small  pieces  of  ice  gives  great  relief,  and  an  ice-bag  may  be  applied  over 
the  tonsillar  region.  For  this  purpose  two  small  bags  of  thin  rubber, 
placed  one  on  each  side  and  kept  in  position,  answer  much  better  than  the 
single  long  sausage-shaped  bag  often  sold  for  this  purpose.  This  latter 
is  usually  much  too  thick,  and  does  not  adapt  itself  well  to  the  neck. 
The  bandage  to  maintain  the  ice-bags  should  go  over  the  top  of  the  head  ; 
not  around  the  neck.  In  other  cases  hot  applications  to  the  neck  give 
more  relief.  Cleansing  sprays  are  indicated,  such  as  liq.  sod.  boratis 
comp.  (Dobell's  solution),  or  hydrogen  dioxide.  Astringent  gargles  are 
of  service  if  the  child  is  old  enough  to  use  them  properly.  Painting  the 
tonsils  with  glycerin  of  tannic  acid,  tincture  of  the  chloride  of  iron  (1  : 3  of 
glycerine)  or  solution  of  nitrate  of  silver  (10  per  cent.)  is  often  of  value. 
My  preference  is  for  the  iron  preparation.  When  such  local  treatment 
causes  great  opposition  on  the  part  of  the  patient,  it  may  be  substituted 
by  the  giving  of  tincture  of  chloride  of  iron  internally  in  doses  of  4  minims 
(0.25)  hourly  at  5  years  of  age.  No  water  should  be  swallowed  immedi- 
ately afterward,  in  order  that  the  drug  may  remain  in  contact  with  the 
tonsils.  In  constantly  recurring  cases  of  lacunar  tonsillitis  with  a  tend- 
ency to  glandular  cnlagement,  removal  of  the  tonsils  may  be  advisable. 

CHRONIC  LACUNAR  TONSILLITIS 

This  disorder  of  the  tonsils  is  sometimes  a  sequel  to  repeated  attacks 
of  acute  inflammation.  It  is  also  an  attendant  in  many  instances  upon 
hypertrophy  of  the  tonsils.  There  is  a  retention  of  the  caseous  material 
in  some  of  the  cr\'pts.  This  may  be  pressed  out,  or  is  discharged  by  the 
act  of  cougliiug,  with  a  resulting  fetid  odor  to  tlie  lireath.  Sometimes 
the  substance  cannot  be  discharged  owing  to  inflammatory  adhesions 
closing  the  orifice  of  the  crj'pt.  The  subjective  symptoms  are  generally 
limited  to  attacks  of  coughing  and  to  slight  pain  or  discomfort  attending 
the  swallowing  of  saliva,  although  solid  food  causes  no  such  sensation. 
At  thnes  acute  exacerbations  occur,  with  fever  (h'veloping  and  with  in- 
crease of  pain.  Treatment  consists  in  opening  and  cauterizing  the  afl'octcd 
crypts;  but  removal  of  the  tonsils  gives  a  more  satisfactory  result. 


682  THE  DISEASES  OF  CHILDREN 

ULCERO-MEMBRANOUS  TONSILLITIS 
(Plaut-Vincent  Angina) 

Although  the  disease  was  known  for  some  years  previously,  its  depend- 
ence upon  specific  germs  was  not  recognized  until  the  investigations  re- 
spectively of  Plaut  and  of  Vincent.  Clinically  it  closely  resembles  many 
cases  of  pseudomembranous  pharyngitis,  and  only  the  presence  of  the 
characteristic  microorganisms  can  render  a  distinction  possible.  The 
germs  producing  it  are  those  seen  in  ulcerative  stomatitis  (p.  657), 
the  pathological  process  the  same,  and  the  two  conditions  may  be 
associated.  It  is  of  much  less  frequent  occurrence  than  other  forms 
of  inflammation  of  the  tonsils,  but  by  no  means  uncommon. 

Etiology. — As  in  ulcerative  stomatitis,  the  disease  is  often  epidemic 
in  hospitals  or  families,  indicating  that  it  is  of  a  somewhat  contagious 
nature;  yet  some  predisposition  to  it  must  be  required,  or  it  would  be  seen 
more  frequently.  It  occurs  oftenest  in  children  and  in  subjects  in  debili- 
tated health.  The  active  cause  appears  to  be  a  symbiosis  of  the  fusiform 
bacillus  and  a  spirochete,  as  already  described  under  Ulcerative  Stoma- 
titis. Both  these  organisms  were  referred  to  by  Miller  ^  as  occurring  in  the 
mouth;  but  their  association  with  this  form  of  tonsillitis  was  first  empha- 
sized by  Plaut  in  1894,'-^  and  later  by  Vincent  in  1898.^ 

Symptoms. — On  one  or,  less  often,  both  tonsils  there  develops  an 
exudate  covering  an  ulcer  of  varying  depth.  In  the  milder  cases  the 
deposit  can  be  readily  removed,  leaving  a  bleeding  surface  beneath.  A 
firm  pseudomembrane,  such  as  is  seen  in  diphtheria,  is  not  produced. 
There  is  little  fever  and  little,  if  any,  constitutional  disturbance.  An 
offensive  odor  of  the  breath  is  present.  The  lymphatic  glands  at  the 
angle  of  the  jaw  are  swollen,  but  do  not  suppurate.  In  the  severer  cases 
the  ulceration  is  much  deeper,  the  constitutional  symptoms  become  more 
marked  and  the  odor  may  be  extremely  offensive. 

Course  and  Prognosis. — In  the  milder  cases  the  course  is  short, 
the  exudate  soon  disappears,  and  recovery  follows  in  a  few  days.  In  the 
severer  the  course  is  tedious,  the  process  may  last  several  weeks,  and 
relapses  may  occur.  The  clisease  may  spread  to  other  parts  of  the 
pharynx  and  even  prove  fatal  through  the  development  of  extensive 
necrosis  or  of  gangrene,  the  child  then  dying  of  a  condition  similar  to  and 
probably  identical  in  nature  with  gangrenous  stomatitis.  (See  p.  659.) 
I  have  seen  this  occur,  but  such  a  result  is  infrequent,  and  recovery 
nearly  always  takes  place. 

Diagnosis.^ — ^The  distinction  is  to  be  made  especially  from  diph- 
theria. The  softness  of  the  deposit  in  the  milder  cases  and  the  greater 
depth  of  the  ulceration  in  others  are  indications  against  diphtheria;  but 
the  only  certain  test  is  a  bacteriological  examination,  and  even  this  some- 
times permits  of  doubt  in  instances  where  the  germs  of  the  two  diseases 
chance  to  be  combined.  There  are  numerous  cases  on  record  supposed 
at  first  to  be  diphtheria,  but  showing  only  the  presence  of  the  fuso- 
spirillary  organisms.  This  was  true  in  73  out  of  265  cases  suspected  of 
being  diphtheria,  and  reported  by  Helm.'*  On  the  other  hand,  Reiche^ 
reported  22  typical  cases  of  Vincent's  angina  with  the  simultaneous 
presence  of  the  diphtheria  bacillus. 

1  Deutsche  med.  Wochen.schr.,  1884,  X,  395. . 

2  Deutsche  med.  Wochenschr.,  1894,  XX,  920. 

3  Bull.  soc.  des  hop.,  1898,  XV,  244. 

^  Journ.  Michigan  State  Med.  Soc,  1910,  IX,  381. 

5  Med.  Klinik,  1914,  No.  33.     Ref.,  Monatsschr.  f.  Kinderh.,  Referat.,  1915,  XIV,  359. 


PARENC HY M ATOUS   TONSILLITIS  683 

Treatment. — This  is  similar  to  that  useful  in  ulcerative  stomatitis, 
chlorate  of  potash  being  the  best  internal  remedy,  combined  with  the 
local  application  to  the  tonsils  of  antiseptic  solutions,  such  as  nitrate  of 
silver  (gr.  5  to  10  (0.32-0.65)  :oz.  1(30));  tincture  of  iodine,  peroxide  of 
hydrogen  (10  to  50  per  cent.)  and  tincture  of  the  chloride  of  iron  (1  :3  of 
glj'cerine).     In  severe  cases  supporting  treatment  is  required. 

PARENCHYMATOUS  TONSILLITIS 
(Phlegmonous  Tonsillitis,  Quinsy,  Peritonsillitis.) 

Etiology. — Quinsy  is  an  uncommon  condition  in  early  life.  In 
infancy  it  is  rare,  and  only  in  later  childhood  oftener  seen,  even  then  being 
much  less  frequent  than  in  adults.  It  is  generally  in  reality  a  peritonsillar 
abscess,  the  process  often  involving  the  tonsil  as  well.  Less  frequently 
it  develops  primarily  in  the  tonsil.  Catarrhal  or  lacunar  tonsillitis  may 
act  as  a  predisposing  cause,  and  there  exists  also  a  decided  family  or 
individual  tendency.  The  exciting  cause  is  infection  by  some  pj'ogenic 
microorganism. 

Symptoms.^ — ^The  attack  begins  with  suddenness  and  severity, 
with  the  ordinar}'  symptoms  of  catarrhal  pharyngitis.  Rapidly,  however, 
the  fever  becomes  high  and  the  pain  in  the  throat  constant  and  severe, 
making  swallowing,  speaking,  or  opening  of  the  mouth  difficult  or  impos- 
sible. The  breath  is  offensive;  the  tongue  badly  coated.  Inspection  at 
first  shows  little  except  a  prominence  in  the  tonsillar  region  upon  one  side 
of  the  throat,  but  palpation  reveals  a  hard,  swollen,  and  very  tender  mass. 
The  absence  of  any  positive  evidence  on  inspection  is  due  to  the  fact  that 
the  inflammation  is  largely  at  first  in  the  deeper  portion  of  the  affected 
region,  around  or  behind  the  tonsil,  and  the  mucous  membrane  is  not 
primarily  inflamed.  As  the  process  advances  the  whole  tonsillar  region 
on  one  side  becomes  very  prominent,  with  the  mucous  membrane  red  and 
swollen  and  the  mass  pushing  the  edematous  uvula  to  the  other  side  of 
the  throat  and  often  apparently  nearly  closing  the  fauces.  The  other 
tonsil  and  the  pharynx  in  general  may  exhibit  a  catarrhal  inflammation. 
Finally  fluctuation  may  sometimes  be  made  out,  although  in  other  in- 
stances this  is  never  discovered. 

With  these  local  manifestations  there  are  increasing  symptoms  of 
illness;  fever  continuing  high,  oppression  and  difficult  respiration  being 
sometimes  present,  the  pulse  rapid,  and  general  restlessness  and  delirium 
perhaps  occurring.  There  may  be  much  pain  and  tenderness  on  moving 
the  neck.  The  patient  is  able  to  take  almost  no  food  or  drink  and  the  gen- 
eral condition  is  most  distressing. 

The  disease  lasts  several  days  or  a  week,  and  then  an  al)S('ess  may 
often  be  seen  to  be  pointimi,  generally  in  the  neighborhood  of  the  anterior 
pillar  of  the  fauces.  Pus  may  be  discharged  and  relief  from  all  symptoms 
be  complete  in  a  few  hours.  In  many  cases,  however,  there  is  no  pus 
evident  and  a  gradual  resolution  takes  place.  Severe  hemorrhage  has 
been  known  to  follow  the  bursting  of  the  abscess,  and  edema  of  the 
glottis  also  has  occurred.     The  prognosis  is,  however,  nearly  always  good. 

Diagnosis. — This  is  usually  easy  after  the  first  few  days.  Palpation 
is  often  of  greater  aid  than  inspection  at  the  beginning  of  the  attack. 

Treatment.     -Early  in  the  ca^e  the  effort  sliould  l»e  made  to  abort- 
the  process.     This  may  sometimes  be  done  by  the  application  of  ice-bags 


684  THE  DISEASES  OF  CHILDREN 

externally  over  the  affected  region,  combined  with  the  sucking  of  pieces 
of  ice.  Later  the  only  methods  open  are  the  efforts  to  give  relief  from 
pain.  The  use  of  ice  should  be  continued.  Sometimes  the  application  of 
a  hot  poultice  externally  and  the  employment  of  hot  water  as  a  gargle 
give  more  relief.  Opiates  internally  are  often  indispensable.  As  soon 
as  any  region  suggesting  fluctuation  can  be  found  incision  should  be 
made.  Even  if  no  pus  is  discovered  relief  may  follow  from  the  local 
blood-letting. 

HYPERTROPHY  OF  THE  TONSILLAR  TISSUE 

There  is  in  childhood  a  special  predisposition  to  hyperplasia  of  the 
tonsillar  tissue.  The  overgrowth  as  oftenest  recognized  is  in  the  faucial 
tonsils,  but  equally  as  frequently  the  pharyngeal  tonsil  is  involved  (ade- 
noid growths),  and  the  tissue  at  the  base  of  the  tongue  (hngual  tonsil)  may 
likewise  be  affected,  although  the  last  is  not  common  in  children.  Gener- 
ally the  process  involves  more  than  one  region,  although  not  by  any  means 
equally.  Probably  the  pharyngeal  tonsil  is  oftenest  attacked  to  an  extent 
productive  of  symptoms.  The  hj^perplasia  may  affect  both  the  lym- 
phatic structure  of  the  tonsil  and  the  connective  tissue  septa,  sometimes 
the  involvement  of  one  predominating,  sometimes  the  other.  Often 
combined  with  this  tonsillar  hypertrophy  is  the  enlargement  of  the 
follicles  visible  on  the  posterior  wall  of  the  pharynx  on  ordinary  inspection 
of  the  throat. 

HYPERTROPHY  OF  THE  FAUCIAL  TONSILS 

Etiology. — The  disease  is  of  very  great  frequency  in  early  life. 
Lennox  Browne^  estimates  that  it  constitutes  37  per  cent,  of  all  diseases 
of  the  fauces  and  pharynx.  Although  sometimes  beginning  in  infancy, 
the  hypertrophy  is  believed  n6t  to  reach  any  decided  degree  until  this 
period  is  passed.  In  my  own  experience,  however,  enlargement  of  the 
tonsils  in  the  1st  year  is  by  no  means  infrequent.  After  this  period  it 
is  extremely  common.  There  is  often  noted  a  marked  family  predis- 
position, several  of  the  children  of  the  family,  and  often  the  parents  as 
well,  showing  the  same  tendency  to  enlargement.  The  general  health 
usually  appears  to  exert  no  influence,  the  subjects  of  the  disease  being 
healthy  in  other  parts  of  the  body.  (See  Lymphatism,  p.  632.)  The 
repeated  occurrence  of  catarrhal  pharyngitis  is  the  chief  exciting  cause. 
Tuberculosis  has  no  etiological  connection. 

Pathological  Anatomy. — The  condition  of  the  tonsil  varies  with 
the  case.  When  not  associated  with  a  temporary  catarrhal  inflammation, 
as  shown  by  the  redness  of  the  mucous  membrane,  the  tonsil  is  large 
and  pale.  In  some  instances  the  overgrowth  is  chiefly  in  the  lymphoid 
tissue,  and  in  these  the  tonsil  is  soft  and  the  lymphoid  element  projects 
in  the  form  of  nodules.  If  the  fibrous  overgrowth  is  in  excess  the  tonsil 
is  hard  and  firm,  broad  bands  of  connective  tissue  crossing  it  in  different 
directions.  The  crypts  of  the  tonsil  frequently  exhibit  yellowish  masses, 
yet  without  showing  the  signs  of  inflammation  characteristic  of  acute 
lacunar  tonsilhtis.  The  hypertrophy  is  nearly  always  bilateral,  yet  one 
tonsil  is  often  more  affected  than  the  other.  Very  frequently  tonsillar 
hypertrophy  is  overlooked  because  the  organ  is  deeply  situated  and 
its  actual  size  is  not  at  first  discovered.     The  overgrowth  in  these  cases  is 

1  The  Throat  and  Nose  and  Their  Diseases,  1899,  348.  . 


HYPERTROPHY  OF  THE  TONSILLAR  TISSUE  685 

chiefly  in  depth  and  width.  At  the  times  when  an  acute  inflammation  is 
superimposed,  the  organ  increases  much  in  size  and  becomes  redder. 

Symptoms. — Examination  shows  the  presence  of  enlargement  of 
the  tonsils  as  described.  It  not  infrequently  happens,  as  stated,  that 
the  overgrowth  has  been  chiefly  in  width  and  depth,  and  the  tonsil  is 
consequently  "submerged, "  being  hidden  by  the  anterior  pillar  and  other 
folds  of  the  soft  palate.  In  such  cases  palpation  with  the  finger,  or 
causing  the  patient  to  gag  reveals  the  degree  of  enlargement  present. 
In  other  instances  the  tonsils  may  be  so  large  that  they  almost  touch  each 
other.  The  general  symptoms  are  not  well  marked,  the  majority  of  those 
formerly  attributed  to  this  condition  depending  in  reality  upon  the  ade- 
noid overgrowth  which  so  frequently  accompanies  the  hypertrophy 
of  the  faucial  tonsils.  Moderate  enlargement  of  the  latter,  if  occurring 
alone,  produces  practically  no  symptoms.  When,  hov/ever,  the  hyper- 
trophy is  great  there  is  often  a  thick  tone  to  the  voice  as  though  there  were 
food  present  in  the  mouth,  and  the  swallowing  of  solid  food  and  even  the 
respuation  may  be  mechanically  interfered  with.  As  a  rule  deglutition 
is  not  painful.  There  is  a  great  tendency  to  repeated,  acute  tonsillar 
inflammation,  and  at  this  time  the  symptoms  are  exaggerated.  The 
lymphatic  glands  in  the  neck  may  become  chronically  enlarged.  Mouth 
breathing  and  snoring  occur  and  deafness  may  result;  but,  again,  these 
conditions  oftener  depend  chiefly  on  the  accompanying  adenoid  hyper- 
trophy. The  enlargement  of  the  tonsil  may  frequently  be  felt  externally. 
In  other  cases,  without  symptoms  other  than  the  chronic  tonsillar  en- 
largement observed  on  inspection,  there  is  a  tendency  to  repeated  attacks 
of  fever  without  discoverable  cause,  general  impairment  of  health,  and 
other  uncharacteristic  symptoms.  That  these  are  due,  in  some  instances 
at  least,  to  a  mild  toxic  condition  produced  by  absorption  from  a  clini- 
cally inflamed  tonsil,  seems  proven  by  the  disappearance  of  symptoms 
after  tonsillectomy. 

Course  and  Prognosis. — The  softer  lymphoid  tonsils  vary  much 
in  size  from  time  to  thne,  being  larger  during  an}''  acute  attack  of  ton- 
sillitis, and  afterward  sometimes  larger,  sometimes  decidedly  smaller 
than  before  this.  There  is  a  natural  disposition  for  them  to  undergo 
progressive  diminution  in  size  as  puberty  is  attained;  but  unfortunately 
before  this  period  is  reached  there  exists  a  constant  tendencj^  to  an  in- 
creasing overgrowth  of  the  connective-tissue  element,  and  tonsils  of  this 
nature  never  exhibit  any  considerable  lessening  in  dimensions.  There 
is  always  a  certain  danger  of  infection  taking  place  through  these  diseased 
bacilli  tonsils,  tubercle  bacilli  and  the  germs  of  the  acute  fevers  entering 
the  system  in  this  way. 

Treatment. — With  the  exception  of  operative  procedure  this  is 
on  the  whole  unsatisfactory.  Astringent  applications  may  do  good  in 
the  cases  where  the  lymphoid  hyper|)lasia  largely  pretlominates.  The 
administration  of  cod-liver  oil,  or  of  iotlide  of  iron  best  in  the  form  of  a 
syrup,  is  sometimes  of  advantage.  Change  of  residence  to  a  dry  climate 
is  often  of  servic'o.  Little  or  no  benefit,  however,  is  to  be  expected  in 
the  cases  in  which  much  connective-tissue  hyperplasia  has  taken  place. 
As  regards  operation,  in  cases  where  the  hypertrophy  is  moderate  and  is 
producing  no  symptoms  it  is  well  to  defer  this  in  the  hope  of  retrograde 
changes  taking  place  as  age  advances.  Yet,  as  stated,  the  presence  of 
hypertrophy  of  the  tonsils  always  occasions  an  clement  of  danger.  In- 
fection of  various  sorts,  as  of  tul)erculosis,  diphtheria,  and  scarlet  fever, 
is  much  more  prone  to  take  place  l)y  this  route  than  in  the  case  of  healthy 


686  THE  DISEASES  OF  CHILDREN 

tonsils.  Whenever,  then,  there  is  frequent  recurrence  of  lacunar  ton- 
sillitis; where  slight  deafness  readily  develops;  where  there  is  increasing 
glandular  swelling  in  the  neck;,  where  the  tonsils  are  very  large;  or  when, 
from  the  constitutional  symptoms,  there  is  reason  to  believe  that  absorp- 
tion is  taking  place,  the  tonsils  should  be  removed.  On  the  other  hand, 
there  has  undoubtedly  existed  a  disposition  to  a  too  prompt  operative 
removal  of  the  tonsils,  often  merely  on  the  ground  that  hypertrophy 
existed.  It  is  by  no  means  understood  just  what  useful  purpose  the 
presence  of  the  organs  fulfils,  and  it  is  a  safe  dictum  that  no  operation 
in  any  region  of  the  body  should  be  urged,  unless  there  are  distinct 
indications  for  it.  In  my  own  opinion  the  presence  of  hypertrophy  of 
the  tonsils  without  other  symptoms  does  not  constitute  such  an  indica- 
tion; and,  further,  the  existence  of  an  etiological  relationship  of  hyper- 
trophy with  any  symptoms  found  should  appear  at  least  extremely 
probable.  The  mere  discovery  of  a  few  small  lymphatic  glands  in  the 
neck,  for  instance,  is  not  an  indication,  inasmuch  as  this  condition  is 
extremely  common  and  may  be  entirely  without  significance.  There  is, 
it  is  true,  little  danger  in  the  operation,  although  severe  and  even  fatal 
hemorrhage  has  been  known  to  occur,  and  repeatedly  septic  inflamma- 
tion of  various  degrees  of  severity  attacking  different  parts  of  the  body 
has  taken  place.  One  should  also  not  expect  from  operation  benefit  of 
symptoms  which  were  in  reality  dependent  upon  adenoid  growths;  and 
the  removal  of  the  tonsils  does  not  prevent  later  attacks  of  pharyngitis. 

For  the  operative  methods  to  be  recommended,  reference  is  made  to 
works  on  Surgery  or  on  Diseases  of  the  Throat.  My  own  preference  is  for 
as  thorough  a  removal  as  possible,  since  it  not  infrequently  happens  that 
hypertrophy  continues  to  increase  in  the  portion  of  the  tonsil  remaining 
after  a  partial  removal,  or  that  the  deeper-lying  diseased  lacunse  had 
not  been  reached,  and  that  repeated  attacks  of  inflammation  continue 
to  take  place  in  these.  This  removal  is  accomplished  by  enucleation. 
Mention  should  be  made  here  of  the  dirty-grey  pseudomembrane  not 
infrequently  seen  upon  tonsillotomy-wounds  within  24  hours  after 
operation.  This  is  a  matter  of  no  significance,  although  it  may  readily 
cause  alarm  from  the  resemblance  borne  to  a  diphtheritic  deposit. 

HYPERTROPHY  OF  THE  PHARYNGEL  TONSIL 

(Adenoid  Vegetations) 

Etiology. — This  is  an"  extremely  common  condition  in  early  life, 
to  which  attention  under  the  title  of  ''Adenoid  Vegetations"  was  first 
directed  by  Meyer. ^  It  is  found,  according  to  different  statistics,  in 
from  1  to  9  per  cent,  of  children  apparently  healthy  in  other  respects 
(Ballenger)."  Although  it  is  especially  in  childhood  that  its  symptoms 
become  marked,  they  are  quite  frequently  observed  in  infancy  also, 
and  the  condition  may  be  even  congenital.  Toward  the  end  of  later 
childhood  the  incidence  diminishes  greatly.  Children  showing  evidences 
of  lymphatism  are  especially  prone  to  adenoid  growths.  Inheritance  is 
an  undoubted  factor  and  a  family  predisposition  is  often  marked,  perhaps 
all  the  children  of  the  family  presenting  well-developed  instances  of  the 
disease.  Dwelling  in  damp  climates;  the  occurrence  of  such  infectious 
diseases  as  measles,  scarlet  fever,  and  diphtheria,  which  are  productive  of 
nasopharyngeal  inflammation;  and  repeated   attacks  of  catarrhal  dis- 

1  Transac.  Med-Chirurg.  See,  1870,  LIII,  191.  Archiv.  f.  Ohrenheilk.,  187.3,  I,  241; 
II,  241. 

2  Diseases  of  the  Nose,  Throat  and  Ear,  4th  Edit.  .333. 


HYPERTROPHY  OF   THE  PHARYNGEAL  TONSIL 


687 


orders  of  the  nose  and  throat  are  also  factors,  although  this  last  oftener 
results  from  the  hj^pertrophy  than  produces  it.  Tuberculosis  and  syphilis 
have  no  causative  influence;  but  the  possibility  of  tuberculous  changes 
taking  place  in  the  growths  and  of  the  entrance  of  tubercle  bacilli  into 
the  system  is  not  to  be  forgotten.     (See  Tuberculosis,  p.  543.) 

Pathological  Anatomy. — The  soft  "adenoid"  structure  resembling 
that  of  the  faucial  tonsils,  which  is  normally  widespread  in  the  naso- 
pharynx especially  on  the  posterior  wall  and  the  roof,  undergoes  hyper- 
trophy and  forms  masses  of  varying  size  (Fig.  236)  reaching  even  that  of 
a  walnut,  and  attached  to  the  underlying  tissue  by  a  broad  base.  These 
may  more  or  less  completely  fill  the  vault  of  the  pharynx  and  cut  off  the 


Front  viexu. 


Fig.  236. — Adenoids  in  Situ. 


Side  view. 


a.  The  vegetations;  h,  Eustachian  orifice;  c,  the  pharynx;  d,  sphenoidal  sinus;  e,  velum 
of  the  palate;  /,  base  of  the  tongue  and  epiglottis.  {Lennox  Browne,  The  Throat  and  Nose 
and  Their  Diseases,  1899,  422;  after  Castex  and  Lacour.) 


passage  of  air  through  the  choana?.  In  young  subjects  they  consist  of 
soft,  spongy,  lymphoid  tissue  well  supplied  with  blood  vessels,  but  after 
a  time  this  grows  denser,  fibrous  and  less  vascular,  resembling  more  the 
connective-tissue  hypertrophy  of  chronically  enlarged  faucial  tonsils. 

Symptoms. — The  manifold  symptoms  may  be  divided  into  those 
chiefly  local  and  direct  and  those  more  general  and  remote  in  nature.  Of 
the  former,  mouth  breathing  is  one  of  the  most  characteristic  (Fig.  237). 
The  degree  and  persistence  of  this  varies  with  that  of  the  obstruction. 
In  the  milder  cases  it  may  have  entirely  escaped  th(>  observation  of  the 
attendants.  In  some  children  it  is  observed  only  during  sleep,  especially 
if  on  the  back,  at  which  time  snoring  is  liable  to  occur,  and  this  is  true 
even  in  infancy.  In  others  the  obstruction  is  sufficient  to  make  the  sleep 
very  restless  and  disturbed,  the  child  trying  ineffectually  to  find  some 
position  in  which  respiration  may  be  easier.  In  cases  of  decided  adenoid 
hypertrophy  the  mouth  hangs  open  during  the  day  as  well;  the  lips  are 
dry;  the  expression  dull  or  stupid;  the  color  of  the  face  sometimes  pale. 
Alteration  in  the  nhnpe  of  the  .no.sc  is  common.  The  nostrils  are  small 
and  narrow,  and  the  lack  of  use  of  these  for  the  iioimal  purpose  of  breath- 


688  THE  DISEASES  OF  CHILDREN 

ing  gives  the  nose  a  "  pinched"  appearance  (Fig.  238).  Sometimes,  how- 
ever, the  upper  portion  of  it  seems  unduly  broad.  Nasopharyngeal  catarrh 
is  an  attendant  sj'^mptom  either  more  or  less  constantly  present  or  occur- 
ring in  repeated  attacks  from  very  slight  exposure.  The  narrowing  of  the 
choanae  and  the  interference  with  the  passing  of  the  nasal  secretion 
backward  is  an  active  factor  in  producing  the  chronic  catarrhal  condition. 
As  a  result  of  this  the  obstruction  to  respiration  is  increased;  the  voice  is 
altered,  developing  a  nasal,  muffled  character;  the  breath  offensive; 
and  the  taste  and  smell  impaired.  A  harrassing  cough  is  often  present, 
especiall}^  at  night,  the  result  of  the  irritation  of  the  larynx  by  the  in- 
spired air,  which  has  not  been  properly  warmed  and  moistened  by  passing 
through  the  nose  in  the  normal  manner.  In  other  children  the  cough 
may  depend  upon  bronchitis,  to  which  the  affected  children  are  greatly 
predisposed.  Deafness  is  a  very  common  symp- 
tom, at  first  temporary  and  developing  with  the 
catarrh;  later  more  or  less  permanent  unless 
treatment  of  the  adenoids  is  promptly  under- 
taken. It  is  the  result  of  the  blocking  of  the 
entrance  of  the  Eustachian  tubes  and  of  the 
catarrhal  processes  in  them  or  in  the  middle 
ear.  The  symptoms  described  depend  partly  on 
the  permanent  obstruction  by  the  adenoid  growths 
and  partly  on  the  associated  catarrhal  condition. 
Consequently  they  vary  from  time  to  time,  being 
on  the  whole  better  in  summer  and  worse  in  the 
winter  season. 

Permanent  bony  deformities  of  the  structure 
Fig.  237. — Adenoid  Face,    of  the  skull  may  be  the  result  of  the  pressure  of 
{Thomson,  Clinical  Ex-   the  adeuoid  tumors  or  the  efforts  at  respiration. 
a^vnation  of  Sick  Children,    There  is  Seen,  namely,  in  some  cases  a  high  and 
'     '    ^^'  narrow  arching  of  the  palate,  and  irregularity  in 

the  position  of  the  teeth  of  the  upper  jaw.  Exophthalmos  is  some- 
times observed.  One  of  the  most  marked  deformities  of  this  sort  is  the 
alteration  of  the  thorax,  oftenest  in  the  form  of  the  keel-shaped  chest 
with  lateral  depression  of  the  lower  portion  of  the  thorax.  This  occurs 
in  patients  who  have  developed  adenitis  early,  and  is  the  result  of  the 
unusual  efforts  at  respiration  required  to  obtain  a  sufficient  amount  of 
air  in  the  lungs.  It  is  best  seen  in  patients  also  the  subject  of  rickets. 
Scoliosis  may  also  result.  Enlargeinent  of  the  cervical  lymphatic  glands  is 
nearly  always  present  at  some  time  in  well-marked  cases. 

But  the  list  of  symptoms  is  by  no  means  complete  with  those  men- 
tioned, and  a  number  of  more  or  less  indirect  or  general  results  are  evident. 
There  is  often  a  decided  retardation  of  menial  development,  sometimes  the 
result  to  a  certain  extent  of  the  impairment  of  hearing.  The  stupid 
expression,  dependent  in  part  upon  this  mental  state  and  in  part  upon  the 
direct  mechanical  effect  of  the  adenoids  in  keeping  the  mouth  hanging 
open  and  in  producing  deafness,  may,  however,  give  only  a  mistaken  idea 
that  the  patient  is  imbecile.  The  growth  of  the  body  is  also  often  inter- 
fered with,  anemia  is  common,  and  the  general  health  suffers.  Among 
other  conditions  sometimes  associated  with  adenoid  hypertrophy  and 
relieved  by  its  removal,  are  stammering  and  stuttering,  laryngospasm. 
spasmodic  croup,  bronchial  asthma,  hoarseness,  headache,  night  terrors, 
enuresis,  chorea,  grinding  of  the  teeth  and  convulsive  attacks. 


HYPERTROPHY  OF  THE  PHARYNGEAL  TONSIL 


689 


Course  and  Prognosis. — Adenoid  growths  are  disposed  to  increase 
gradually  in  size  and  the  symptoms  consequently  to  grow  worse,  reaching 
their  height  about  the  beginning  of  later  childhood  and  continuing  until 
puberty  unless  relieved  by  treatment.  At  puberty  there  is  a  tendency 
for  the  growths  to  become  smaller  and  for  sjTnptoms  to  disappear,  unless 
the  tissue  has  become  of  a  fibrous  nature.  •  So,  too,  the  conditon  is  always 
better  in  summer  time  and  in  a  dryer  climate,  due  to  the  diminution  of 
the  catarrhal  involvement  of  the  mucous  membrane  and  the  shrinking  of 


t 


Fig.  23S — Defor.\uty  i^hum  Aue.noiu  C;howths. 
Child  of  7  years  and  9  months.      Shows  the  narrow  nasal  bridge  and  sm.all  nostrils,  aa 
well  as  a  marked  degree  of  funnel-chest  from  persistent  respiratory  tugging. 


the  growths;  worse  in  winter  and  during  the  occurrence  of  an  acute  naso- 
pharyngeal catarrh.  Owing  to  this  disposition  to  grow  worse,  there  is 
a  likelihood  of  serious  deformities  and  affection  of  the  health  developing. 
This  is  particularly  true  when  symptoms  have  appeared  during  infancy. 
Infection  of  various  sorts,  especially  by  tuberculosis  and  diphtlicria,  is 
liable  to  occur  by  way  of  the  adenoids,  and  the  presence  of  those  vegeta- 
tions  makes  many  diseases  affecting  the  throat  run  a  more  serious  course. 
The  results  from  operative  treatment  are  somotimos  remarkably  prompt 
and  complete;  oftenor  somewhat  slower  in  numifcsting  themselves;  some- 
times disappointing  if  the  adenoids  hjive  been  allowed  to  remain  too  long 
and  if  bony  deformities  or  nervous  symptoms  have  developed. 

44 


690  THE  DISEASES  OF  CHILDREN 

Diagnosis. — In  well-marked  cases  this  presents  little  difficulty. 
The  presence  of  the  characteristic  obstructive  symptoms  described  is 
most  suggestive,  especially  the  mouth-breathing  and  snoring,  the  expres- 
sion of  the  face,  occurrence  of  deafness,  and  the  obstinate  or  frequently 
recurring  nasal  catarrh.  The  existence  of  hypertrophied  faucial  tonsils 
indicates  that  adenoids  are  very  probably  present  also.  The  diagnosis 
can  be  confirmed  by  digital  examination  of  the  vault  of  the  pharynx. 
This  reveals  the  irregular,  soft,  nodular  masses,  or  sometimes  a  tough, 
firmer  growth.  Slight  bleeding  nearly  always  follows  the  examination. 
In  older  children  the  masses  may  be  seen  by  rhinoscopic  examination. 
Even  in  patients  suffering  from  vague  symptoms,  such  as  headaches,  ane- 
mia, debility,  various  nervous  manifestations,  mental  backwardness,  and 
so  on,  one  should  make  sure  whether  or  not  it  is  the  presence  of  adenoids 
which  perhaps  accounts  for  the  condition. 

Treatment. — Owing  to  the  tendency  to  increase  in  size  and  the 
many  dangers  which  attend  the  presence  of  adenoids,  the  best  treatment 
is  undoubtedl}^  their  early  and  thorough  removal.  Delay  may  be  made, 
however,  where  the  growths  are  small  and  but  little  obstruction  occurs, 
and  where  the  symptoms  can  be  relieved  by  change  of  climate,  espe- 
cially in  winter,  or  by  successful  measures  to  prevent  catarrhal  attacks. 
Such  patients  should,  however,  be  under  constant  medical  supervision. 
In  the  meantime  efforts  should  be  made  to  maintain  and  improve  the 
general  health  by  tonic  remedies,  especially  cod-liver  oil.  Positive  indi- 
cations for  prompt  operative  interference  are  continuous  mouth-breath- 
ing, affection  of  speech,  otitis,  deafness,  beginning  bony  deformities, 
retarde<:l  mental  or  bodil}^  development,  and  persistent  or  constantly  re- 
curring nasal  catarrh  and  bronchitis.  Asthma,  cervical  adenitis,  enuresis, 
night  terrors,  headache,  and  other  nervous  symptoms  not  relieved  by 
other  treatment  often  make  adenotomy  advisable. 

Although  operative  removal  is  such  an  effectual  treatment  in  this 
disease,  it  should  not  be  practised  merely  as  a  routine  measure,  but  de- 
termined for  each  individual  case.  To  operate  needlessly  is  as  much  a 
fault  as  is  the  failure  to  operate  when  indicated.  The  age  for  operation 
is  the  time  when  serious  symptoms  are  threatening,  even  in  infancy. 
When,  however,  it  can  be  deferred  without  danger  it  is  better  to  wait 
until  infancy  is  past.  So,  too,  spring  or  summer  is  the  season  to  be 
elected  for  operation  when  this  can  be  managed  without  detriment, 
since  catarrhal  nasal  disorders  are  less  likely  to  complicate  the  condition 
at  this  time.  Operation  should  not  be  performed  during  an  attack  of 
rhinitis.  Thorough  removal  is  a  bloody  and  sometimes  a  rather  tedious 
operation,  to  be  performed  under  ether.  It  is,  however,  in  my  experience, 
much  to  be  preferred  to  a  rapid  partial  removal,  since  recurrence  of  the 
growth  is  very  likely  to  follow  the  latter  procedure.  The  operation 
should  be  done  only  by  one  giving  especial  attention  to  this  branch  of 
surgery,  and  details  may  well  be  omitted  here.  Excessive  and  even 
fatal  hemorrhage  has  occurred  either  during  the  operation  or  afterward, 
and  nephritis  has  sometimes  developed.  I  have  seen  several  instances  of 
this.  Sudden  death  under  the  anesthetic  has  also  been  seen,  due  doubt- 
less to  the  accompanying  lymphatism  frequently  present.  After  opera- 
tion the  denuded  surface  affords  a  ready  portal  of  entry  for  diphtheritic, 
scarlatinal  or  septic  infection.  On  the  whole,  however,  these  accidents 
are  uncommon  and  the  danger  of  operation  is  very  slight. 


MALFORMATIONS  OF  THE  ESOPHAGUS 


691 


CHAPTER  IV 


DISEASES  OF  THE  ESOPHAGUS 
MALFORMATIONS  OF  THE  ESOPHAGUS 

These  are  occasionally  seen  in  early  life,  and  most  of  them  are  of 
congenital  origin.  In  conjunction  with  Dr.  R.  S.  Lavenson,  I  have  re- 
viewed the  subject  to  some  extent  in  a  previous  publication^  where  a  bib- 
liography ma}'  be  found.  Some  of  these  malformations  are  incompati- 
ble with  life  and  the  infant  dies  a  few  days  after  bii'th;  others  may  be 
continued  indefinitely.  A  statistical  review  of  the  subject  has  been 
published  by  Cautley.^    Among  the  malformations  may  be  mentioned: 

1.  Branchial  Fistulae  and  Cysts  are  the  result  of  a  failure  of  complete 
closure  of  the  branchial  cleft,  which  opens  in  fetal  life  through  the  neck 

into  the  upper  part  of  the  esophagus  or  the  

lower  portion  of  the  pharynx.  It  consists  of  a 
small,  external  fistula  usually  unilateral,  and 
oftenest  just  above  the  sternoclavicular 
articulation;  sometimes  high  in  the  neck  at 
the  inner  edge  of  the  sternocleidomastoid 
muscle.  The  fistula  ends  blindly  or  may 
communicate  with  the  alimentary  tract. 
Treatment  is  usually  unsatisfactory  and  had 
better  not  be  attempted  except  in  those  cases 
where  there  is  a  continual  mucous  discharge, 
or  where  the  external  opening  of  the  fistula 
has  become  clogged  and  a  disfiguring  cj'st- 
like  mass  results.  Cysts  of  a  similar  ap- 
pearance, due  to  other  causes,  occur  in  this 
localit3\  To  all  such  growths  the  title 
Hygroma  is  often  applied  (Fig.  239). 

2.  Diverticula  of  the  esophagus  are  oc- 
casionally seen.  It  is  doubtful  whether  they 
are  ever  reall}^  congenital.  They  occur  most 
frequently  as  the  result  of  traction  exerted 
by  adhesions  of  the  esophagus  to  the  trachea 
or  to  a  bronchial  gland.  Their  situation  is 
oftenest  at  the  level  of  the  bifurcation  of  the  trachea.  The  food  taken, 
especially  if  solid,  experiences  difficulty  in  passing  into  the  .stomach, 
and  often  is  regurgitated  after  a  shorter  or  longer  interval  without 
nausea  and  without  evidences  of  action  of  the  gastric  secretion.  In  some 
cases  swelling  upon  one  side  of  the  neck  is  present  when  the  diverticulum 
is  distended  by  food.  The  sound  when  passed  may  catch  in  a  pocket 
somewhere  in  the  course  of  the  esophagus,  or  may  at  other  times  pass 
into  the  stomach.  The  employment  of  the  .r-ray  after  the  administration 
of  bismuth  serves  to  confirm  the  diagnosis  of  divcrticuhini. 

3.  Congenital  absence  of  the  esophagus  is  very  rare.  There  were  found 
but  7  report (>(1  cases. 

4.  Congenital  stenosis  is  uncommon.  It  is  due  either  to  a  fold  of 
mucous  meml)rane  or  to  narrowing  of  the  entire  wall  of  the  tube.     It  is 


Fig.  239. — Hygroma  Cysticum. 
Patient  aged  7  months,  in 
the  Children's  Hospital  of 
Philadelphia.  Tumor  was 
noticed  at  birth,  grew  steadily 
larger,  and  finally  interfered 
with  respiration  and  deglutition. 


'  .\rcli.  of  Pediat.,  l!tU9,  XXVI,  ItU. 
=  Brit.  Jour.  Child.  Dis.,  1917,  XIV,  1. 


692 


THE  DISEASES  OF  CHILDREN 


attended  by  the  symptoms  of  stenosis  seen  in  the  acquired  form.     (See 
p.   694.) 

5.  Dilatation  of  the  esophagus  as  a  congenital  lesion  is  limited  to  the 
portion  just  above  the  diaphragm.  A  consequent  acquired  secondary 
diffuse  dilatation  of  the  entire  length  of  the  esophagus  may  result.  Ac- 
quired dilatation  is  liable  also  to  be  a  sequence  to  stenosis  of  any  nature, 

but  is  oftenest  seen  in  corrosive  esophagitis  with 
stricture.     (See  p.  694.) 

6.  A  partial  or  complete  doubling  of  the 
esophagus  has  been  observed  in  2  or  3  instances. 

7.  Sometimes  a  tracheo-esophageal  fistula 
exists  without  other  lesions.  This  is  very  rare. 
(See  below). 

8.  Finally  there  may  be  a  congenital  ob- 
literation of  the  lumen  of  the  esophagus  in  a 
portion  of  its  extent.  Unattended  by  fistula 
this  is  very  uncommon.  We  found  but  17 
published  cases,  ^  but  a  number  of  others  have 
since  been  reported.  The  most  common  con- 
genital malformation  of  the  esophagus  is  a 
combination  of  obliteration  through  more  or 
less  of  its  extent  with  tracheo-esophageal  fistula, 
connecting  the  trachea  just  above  the  bifurcation 
with  the  portion  of  the  esophagus  below  the 
closure  (Fig.  240).  The  upper  portion  of  the 
esophagus  is  somewhat  dilated  and  ends  blindly 
at  the  point  of  obstruction.  The  chief  symptom 
of  obliteration  is  the  complete  inability  to 
swallow  food;  it  being  promptly  regurgitated 
through  the  mouth  and  nose,  producing  severe 
suffocative  attacks.  Attempts  to  pass  a  sound 
encounter  the  obstruction. 

SPASM  OF  THE  ESOPHAGUS 

(Esophagismus) 

Although  a  disease  oftenest  seen  beyond 
puberty  and  in  women,  cases  occasionally  occur 
in  children,  and  I  have  encountered  1  very  typical 
instance."  A  neurotic  or  psycopathic  element 
is  present,  and  the  condition  is  much  influenced 
by  observation,  sympathy,  and  the  like.  The 
difficulty  in  swallowing  may  be  constantly 
present,  or  may  occur  only  at  intervals  under  in- 
creased nervous  excitement.  In  some  cases  liquids 
can  be  taken  readily,  although  solids  give  trouble;  while  in  others  there  is 
difficulty  with  both  sorts  of  nourishment.  Sometimes  hot  liquids  can  be 
swallowed  better  than  cold.  The  diagnosis  is  to  be  made  especially 
from  organic  stricture  by  the  fact  that  an  esophageal  bougie  passes 
without  difficulty,  at  least  under  anesthesia.  The  prognosis  is  good  so 
far  as  life  is  concerned,  but  the  duration  of  the  disorder  is  often  long. 
Treatment  should  be  directed  especially  to  the  nervous  system.  Sym- 
pathy and  over-anxiety  should  not  be  shown  by  the  parents ;  a  skillful  nurse 

J-  Loc.  cit. 

2  New  York  Med.  Journ.,  1914,  XCIX,  113. 


Fig.  240. — Diagram 
Illustrating  Tracheo- 
esophageal  Fistula. 

(Griffith  and  Lavenson, 
Trans.  Amer.  Pediat.  Soc, 
1908,  XX,  86.) 


ESOPHAGITIS  693 

is  of  great  aid ;  and  the  patient  does  better  if  removed  from  home.  Gen- 
eral tonic  and  hygienic  measures,  change  of  air,  and  the  like  are  service- 
able.    It  may  be  well  to  pass  a  bougie  daily. 

CATARRHAL  AND  FOLLICULAR  ESOPHAGITIS 

Acute  catarrhal  esophagitis  may  occur  under  a  variety  of  condi- 
tions, and  may  be  seen  even  in  the  newborn  (Billard).^  It  maj'  occur 
in  the  course  of  the  acute  infectious  diseases  or  pneumonia;  attend 
catarrhal  inflammation  of  other  parts  of  the  digestive  tract;  or  follow 
lacerations  produced  by  the  swallowing  of  foreign  bodies  or  the  injury 
done  by  the  ingestion  of  hot  liquids.  The  mucous  membrane  is  injected 
and  swollen  and  the  subcutaneous  connective  tissue  edematous.  Super- 
ficial erosions  may  occur  in  severe  cases.  The  lesions,  as  far  as  known, 
generally  last  but  a  few  days,  and  the  prognosis  is  favorable.  Symptoms 
are  absent  or  are  uncharacteristic  and  consist  of  mild  pain  on  swallowing. 

Chronic  catarrhal  esophagitis  is  of  unusual  occurrence  in  early  life. 
It  may  follow  an  acute  catarrhal  process,  or  be  the  result  of  venous  con- 
gestion in  chronic  pulmonary  or  cardiac  disease. 

Follicular  esophagitis  is  probably  more  uncommon  than  the  catarrhal 
variet3^  It  has  been  found  in  typhoid  fever  and  in  chronic  gastro- 
intestinal and  respiratory  diseases.  The  lesions  consist  in  enlargement  of 
the  mucous  follicles,  sometimes  attended  by  superficial  erosion  of  them. 

A  secondary  esophagitis  of  a  different  nature  from  the  lesions  described 
may  occur  in  the  course  of  various  diseases,  but  is  rare.  Thus  diphthe- 
ritic or  other  pseudomembranous  inflammation  has  been  found  in  the 
esophagus;  thrush  may  extend  into  it  and  even  obstruct  its  lumen; 
pustules  of  variola  have  been  discovered  there;  and  ulceration  may  result 
from  perforation  of  a  caseous  lymphatic  gland.  As  with  the  other  forms 
of  esophagitis  mentioned,  the  recognition  is  usually  impossible  during 
life. 

CORROSIVE  ESOPHAGITIS 

(Stricture  of  the  Esophagus) 

Corrosive  inflammation  is  the  variety  of  esophagitis  oftenest  seen  in 
children.  The  most  frequent  cause  is  swallowing  of  caustic  solutions  such 
as  strong  acids  or  alkalies,  given  to  the  children  by  mistake,  or  carelessly 
allowed  to  be  within  their  reach.  The  lesions  depend  upon  the  strength 
and  amount  of  the  fluid  ingested  and  the  degree  of  penetration  of  the  cor- 
roding process,  this  varying  from  a  superficial  necrosis  of  the  epithelium 
to  a  destruction  of  the  entire  thickness  of  the  mucous  membrane.  In  the 
severer  cases  a  slough  results  which  finally  separates,  and,  if  the  pa- 
tient survives,  is  at  last  replaced  by  cicatricial  connective  tissue,  resulting 
finally  in  stenosis  as  contraction  takes  place.  In  the  worst  cases  even 
perforating  ulceration  of  the  esophageal  wall  occurs. 

Symptoms. — The  early  symptoms  are  immediate  pain  and  burning 
from  the  mouth  downward,  with  vomiting  of  bloody  mucus;  painful 
or  impossible  deglutition;  and  great  thirst.  Total  collapse  may  occur 
at  once,  and  death  take  place  in  a  few  hours  or  days;  or  somnolence  and 
fever  may  mark  the  severity  of  the  toxic  action.  If  the  danger  of  early 
death  is  passed,  there  remains  for  some  days  the  evidence  of  severe  local 
inflammation  with  great  pain  especially  on  swallowing.  The  mucous 
membrane  of  the  mouth  is  in  places  denuded  of  epithelium.  Vomiting 
of  pieces  of  necrosed  nnicous  membrane  may  occur.  Later  death  may 
1  Traitc  des  inal.  des  nouveaux-nes,  1828,  274. 


694  THE  DISEASES  OF  CHILDREN 

result  from  perforation  into  the  peritoneal  or  the  pleural  cavity.  If 
this  does  not  occur,  improvement  gradually  follows,  although  erosion  of 
the  blood-vessels  or  perforation  of  an  ulcer  may  later  unexpectedly  take 
place.  After  an  interval  usually  of  some  weeks  or  months  the  symptoms 
of  stricture  of  the  esophagus  begin,  if  the  corrosive  action  has  been 
more  than  merely  superficial.  There  is  then  an  increasing  difficulty  ex- 
perienced in  swallowing  solid  food,  which  often  is  regurgitated  after  the  at- 
tempt is  made.  Finally,  in  severe  cases,  even  liquid  iood  is  ejected,  and 
examination  with  the  sovuid  shows  a  more  or  less  complete  stricture  of 
the  tube.  The  position  of  the  stricture  and  its  character  vary.  It  may 
be  annular  or  cylindrical  in  form.  In  the  majority  of  cases  in  children 
it  is  situated  in  the  upper  third  of  the  esophagus.  Torday^  found  it  in 
the  upper  third  in  54  per  cent,  of  his  cases,  and  in  the  middle  third  in  19 
per  cent. 

It  should  be  borne  in  mind  in  this  connection  that,  although  the  great 
majority  of  cases  of  stricture  of  the  esophagus  are  dependent  upon  cor- 
rosive esophagitis,  there  are  exceptions  of  various  sorts.  Congenital 
atresia  or  stricture  of  the  esophagus  has  already  been  referred  to  (pp.  691, 
692).  There  may  further  be  mentioned  stricture  from  the  lacerations 
produced  by  foreign  bodies,  and  a  spasmodic  stenosis  occurring  in  hys- 
teria or  rabies;  while  diphtheria,  syphilis,  and  variola  have  produced 
the  disease  by  ulceration.  Narrowing  by  compression  from  without  may 
occur  in  cases  of  retroesophageal  abscess,  inflammatory  enlargement  of 
the  thyroid  gland  and  caseous  tracheobronchial  glands. 

After  the  development  of  cicatrical  stricture  a  dilatation  of  the  esopha- 
gus, either  cylindrical  or  sacculated,  generally  forms  above  it  and  food 
may  lie  for  some  time  in  this  before  being  regurgitated.  If  the  stricture 
is  decided,  rapid  loss  of  we'ght  and  of  general  health  will  occur.  There  is, 
however,  frequently  a  certain  degree  of  variability  in  the  completeness 
of  the  obstruction,  and  children  may  be  able  to  swallow  fairly  well  at 
certain  times  and  not  at  all  at  others.  This  probably  depends  upon  a 
varying  increase  and  decrease  in  the  swelling  of  the  mucous  membrane. 

Prognosis. — The  prognosis  of  corrosive  esophagitis  is  always  serious 
and  uncertain.  A  large  number  perish  from  the  primary  lesion,  and  of 
those  who  survive  a  considerable  part  die  of  stricture.  Torday  report- 
ing on  208  cases  of  corrosive  esophagitis  in  children  produced  by  the 
ingestion  of  lye,  found  that  172  (82.69  per  cent.)  later  developed  the  evi- 
dences of  stricture;  the  percentage  being  the  same  as  occurred  in  the 
experience  of  Keller"  (82  per  cent.)  many  years  earlier.  Cases  where  the 
lesions  of  the  mouth  and  pharynx  soon  heal  probably  also  have  an  involve- 
ment of  the  esophagus  which  is  likewise  mild,  and  the  prognosis  is  conse- 
quently better. 

Treatment. — The  first  indications  for  treatment,  if  the  child  is  seen 
early  enough,  are  the  exhibition  of  antidotes  to  the  corrosive  poison  and 
the  washing  out  of  the  stomach.  After  this  the  administration  of  ice  and 
of  demulcent  solutions  internally  is  indicated,  such  as  oil,  flaxseed  or 
gum  arable  solution,  and  the  hke,  with  morphine  hypodermically  to  relieve 
the  suffering.  Any  food  given  must  be  liquid  and  perhaps  best  adminis- 
tered by  rectum  if  the  child  will  retain  it.  In  cases  in  which  stricture 
has  developed,  the  treatment  is  purely  surgical  and  consists  in  the  system- 
atic and  very  careful  use  of  bougies  of  a  progressively  increasing  size, 

1  Jahrb.  f.  Kinderheilk.,  1901,  LIII,  272. 

2  Oesterreich.  Zeitsch.  f.  Heilkund.,  1862,  VIII,  856. 


RETROESOPHAGEAL  ABSCESS  695 

beginning  with  small  instruments  when  necessary.  This  procedure  should 
not  be  commenced  until  at  least  3  or  4  weeks  have  elapsed,  and 
all  acute  symptoms  have  subsided.  If  no  bougie  can  be  passed,  gastros- 
tomy becomes  necessary,  followed  by  an  attempt  to  dilate  the  stricture 
from  the  cardia.  The  use  of  bougies  must  be  continued  for  months  in 
order  to  prevent  recurrence  of  the  strictm-e. 

FOREIGN  BODIES  IN  THE  ESOPHAGUS 

With  the  disposition  of  children  to  put  all  sorts  of  objects  in  the  mouth, 
the  lodging  of  foreign  bodies  in  the  esophagus  is  of  not  infrequent  occur- 
rence. Careful  examination  with  the  esophageal  sound  will  reveal  the 
presence  of  the  body  and  its  position,  and  the  use  of  the  Rontgen  ray 
is  of  great  aid  in  confirming  the  diagnosis.  The  place  of  lodgment  is 
oftenest  either  at  the  upper  opening,  or  lower  where  the  left  bronchus 
crosses  the  tube.  The  removal  of  such  bodies  has  become  a  strictly 
surgical  procedure,  the  object  being  pushed  into  the  stomach,  or  with- 
drawn through  the  mouth.  Skill  is  required  to  avoid  doing  injury. 
Sometimes  esophagotomy  is  required.  Should  the  object  pass  into  the 
stomach  amylaceous  food,  such  as  potato  and  cereals,  should  be  given 
freely  in  order  to  render  the  feces  consistent  and  thus  coat  the  foreign 
body  and  protect  the  bowel  from  injury. 

RETROESOPHAGEAL  ABSCESS 
(Periesophageal  Abscess) 

This  rare  condition  is  sometimes  seen  in  infancy  and  childhood.  But 
1  instance  has  come  to  my  observation,  and  a  study  of  the  literature  in 
1898^  found  but  12  others  reported  in  detail  up  to  that  time. 

Etiology. — The  causes  are  similar  to  those  producing  retropharyngeal 
abscess,  except  that  spinal  caries  appears  here  to  be  the  most  frequent 
etiological  factor.  Among  other  causes  which  may  induce  periesopha- 
geal inflammation  are  pleuritis  and  pericarditis;  ulceration  resulting  from 
a  foreign  body  in  the  esophagus,  or  from  a  tracheotomy  tube  or  intubation 
tube;  diphtheria  of  the  pharynx;  and  suppurating  lymphatic  glands. 
The  abscess  forms  behind  and  around  the  esophagus  and  often  displaces 
it  readily  to  one  side,  while  it  exercises  compression  upon  the  more  firmly 
seated  trachea  or  on  other  parts. 

Symptoms. — These  are  very  uncharacteristic  and  misleading. 
Dyspnea  is  nearly  always  present  and  is  the  most  prominent  and  urgent 
symptom.  Cough,  too,  is  generally  observed;  sometimes  only  slight, 
sometimes  spasmodic  or  brassy  and  suggesting  stenosis.  Dysphagia 
might  be  expected,  but  was  absent  in  all  the  reported  cases  in  my  series. 
This  is  doubtless  due  to  the  fact  that  the  esophagus  yields  easily  to  the 
pressure  and  changes  its  position.  Swelling  in  the  neck  may  result  if 
the  abscess  is  situated  behind  the  upper  part  of  the  esopliugus.  Affec- 
tion of  the  voi(;e  is  vmcommon  and,  in  any  event,  does  not  present 
the  peculiar  characteristic  nasal  alteration  observed  in  retropharyngeal 
abscess. 

Prognosis. — The  prognosis  is  nearly  always  unfavoral)le.  Death 
may  result  from  the  pressure  of  the  abscess  upon  the  pneuniogastric 
nerve,  or  on  the  trachea  with  consequent  asphyxia;  or  rupture  into  the 
trachea,  bronchi  or  lung  may  occur  and  a  purulent  bronchitis  or  broncho- 

1  Univ.  Mod.  Mhr.,  1S9S.  Jmu. 


696  THE  DISEASES  OF  CHILDREN 

pneumonia  follow.  Even  should  the  abscess  discharge  itself  into  the 
esophagus,  asphyxia  from  the  pus  being  regurgitated  and  entering  the 
larynx  in  large  quantities  may  take  place.  If  this  passing  into  the  larynx 
is  escaped,  recovery  may  follow.  Unfortunately  the  spondyhtis  which  is 
the  commonest  cause  of  abscess  remains,  suppuration  continues,  and  the 
danger  of  pus  entering  the  larynx  exists  for  every  future  occasion  of  the 
discharge  of  it  in  large  amount. 

Diagnosis. — This  is  always  difficult  and  generally  cannot  be  more 
than  conjectural,  since  other  pathological  conditions  may  produce  very 
similar  symptoms.  If  caries  of  the  vertebra  is  known  to  exist,  retro- 
esophageal abscess  may  be  suspected  if  the  dyspnea  and  other  symptoms 
as  described  develop.  If  the  abscess  has  a  very  high  situation  it  may  per- 
haps be  reached  by  the  finger  thrust  deeply  downward  through  the 
pharynx,  or  a  lateral  swelhng  in  the  neck  may  be  visible.  If  there  is  a 
history  of  the  swallowing  of  a  foreign  bodj^,  employment  of  the  Rontgen 
ray  maj^  reveal  the  presence  of  an  abscess. 

Treatment. — Therapeutic  measures  can  seldom  be  employed.  If 
the  abscess  is  situated  high  enough  to  be  discoverable  by  the  finger 
it  may  be  opened.  Otherwise  nothing  directly  in  the  way  of  treatment 
can  be  done.  Tracheotomy  may  be  performed  if  there  is  urgent  dyspnea; 
not  with  the  hope  of  relief  if  the  condition  is  due  to  retroesophageal 
abscess,  but  because,  with  the  uncertain  diagnosis,  some  other  disorder 
may  be  the  cause  of  the  respiratory  stenosis. 


CHAPTER  V 
DISEASES  OF  THE  STOMACH    AND  INTESTINES 

In  the  absence  of  a  fully  complete  knowledge  of  the  physiology  of 
digestion  and  of  the  pathological  lesions  found  in  the  digestive  tract,  -any 
classification  of  the  diseases  of  the  stomach  and  intestines  can  be  only 
provisional.  That  based  either  upon  the  lesions  alone  or  upon  etiology 
alone  is  no  more  practically  useful  than  is  that  scientific  which  rests  solely 
upon  symptoms;  since  the  same  lesions  may  be  productive  of  different 
symptoms,  and,  on  the  other  hand,  identical  symptoms  may  be  the  re- 
sult of  quite  diverse  pathological  causes.  There  are  diseases,  too,  which 
appear  to  depend  entirely,  or  in  great  part,  upon  functional  disturbances 
rather  than  upon  pathological  lesions,  and  it  is  often  difficult  or  impossible 
to  determine  from  clinical  manifestations  how  far  the  disordered  condition 
is  due  to  one  or  the  other  factor.  The  role  of  microorganisms  and  their 
toxins  is  also  important  in  the  production  of  gastrointestinal  disease; 
the  bacteria  being  either  those  foreign  to  the  alimentary  canal,  or  those 
which  are  natural  inhabitants  of  it  under  ordinary  circumstances,  and  are 
then  without  harmful  influence.  This  role  is,  however,  uncertain;  some- 
times the  affection  being  probably  chiefly  a  disturbance  of  function  through 
the  poisonous  toxins;  sometimes  a  distinct  pathological  infection  produced 
by  the  germs;  although  just  which  action  predominates  cannot  well  be 
determined.  Indeed  of  recent  years  the  influence  of  germs  in  producing 
gastrointestinal  disorders  has  been  largely  called  in  question  in  many 
quarters,  and  many,  of  the  disturbances  of  this  sort  are  assigned  to  meta- 
bolic processes  depending  often  upon  the  nature  of  the  food  given. 

Again  it  is  evident  that  the  diseases  of  the  stomach  and  of  the  intestine 
respectively  cannot  be  always  sharply  separated  from  each  other,  since 


THE  FINKELSTEJN  CLASSIFICATION  697 

SO  often  the  symptoms  of  both  may  appear  simultaneously  or  consecu- 
tively, or  sometimes  those  of  the  one  region  predominating  and  sometimes 
of  the  other.  With  these  facts  in  view  the  difficulties  attending  any 
classification  are  manifest. 

THE  FINKELSTEIN  CLASSIFICATION 

The  theories  of  Finkelstein  regarding  nutritional  diseases  associated 
with  disordered  digestion  or  metabolism;  an  elaboration  and  modifica- 
tion of  the  views  of  Czerny  and  Keller^  have  attracted  so  much  attention 
that  a  review  of  them  is  necessary.  The  classification  is  given  at  length 
in  the  article  by  Finkelstein  and  Meyer  in  Feer's  work  on  Pediatrics^ 
and  previously  in  many  journal-publications.  (See  also  reviews  by 
J.  Hess,^  Meara,^  and  others;  and  especially  by  Snow.^)  Instead  of  classi- 
fying the  disorders  according  to  the  portions  of  the  digestive  tract  exhibit- 
ing symptoms,  or  viewing  them  as  dependent  upon  baterial  action,  he 
regards  them  rather  as  disturbances  of  metabolism,  the  result  of  the  toxic 
action  of  substances  derived  from  the  different  normal  elements  of  the 
food,  given  in  a  combination  unsuited  to  the  child.  The  sjanptoms, 
then,  are  evidences  of  intoxication  rather  than  of  infection.  The  element 
of  decomposition  of  the  food  by  the  action  of  bacteria,  as  in  impure 
milk,  he  considers  as  of  minor  importance.  The  healthy  breast-fed 
baby  has  a  normal  tolerance  for  food;  but  the  artificially-fed  infant  has 
to  deal  with  food-ingredients  not  natural  to  it,  and  a  degree  of  intoler- 
ance for  some  of  these  is  readily  established.  This  is  especially  true  if 
the  child  is  weakly,  or  the  digestive  functions  disordered  There  is  a 
loss  of  the  natural  balance  between  the  food  required  and  the  ability  of 
the  child  to  assimilate  this.  The  casein  of  the  milk  is,  according  to  his 
view,  the  ingredient  most  readily  borne.  The  whey,  on  the  other  hand, 
is  a  source  of  much  trouble.  The  sugar  and  the  fat  readily  produce 
intolerance,  but  chiefly  when  given  in  combination  with  or  contained  in 
the  whey.  Abnormal  fermentation  of  the  food  in  the  digestive  tract 
occurs,  for  instance,  during  hot  weather  from  a  diminution  of  the  power  of 
digestion  rather  than  from  unusual  contamination  by  bacteria. 

The  development  of  intolerance  may  be  shown  by  various  symptoms, 
their  nature  depending  upon  the  severity  of  the  process.  These  symp- 
toms are  not  only  those  distinctly  digestive,  such  as  vomiting,  diarrhea, 
and  the  like,  but  others  of  deranged  metabolism  producing  nervous 
manifestations,  albuminuria,  fever,  etc. 

Finkelstein  divides  the  disturbances  into :  (1)  Disturbance  of  balance ; 
(2)  Dyspepsia;  (3)  Decomposition,  and  (4)  Intoxication. 

1.  Disturbance  of  Balance, — This  is  the  mildest  modification  of  the 
food-intolerance.  The  most  common  injurious  element  of  the  food  is 
the  fat.  This  is  not  necessarily  because  the  fat  is  in  an  unduly  large 
amount,  but  because  the  increased  alkaline  secretion  of  the  intestines 
combine  with  the  fatty  acids  producing  soap-stools.  The  chief  symptoms 
are  unsatisfactory  gain  in  weight  in  spite  of  the  administration  of  food 
the  caloric  value  of  which  is  sufficient.  There  is  to  some  extent  a  "para- 
doxical reaction";  i.e.  a  greater  loss  of  weight  if  the  food  is  increased. 

*  Des  Kindes  Erniihrung,  Ernahrungstorungen  und  Erniihrungstherapie,  1906,  II. 

2  Feer,  Lehrbuch  der  Kinderheilkundc,  1914,  223. 

3  Amer.  Jour.  Dis.  Child.,  1911,  II,  422. 

*  Arch,  of  Ted.,  1910,  XXVII,  579. 

"  Arch,  of  Fed.,  1909,  XXVI,  801.     Amer.  Journ.   Dis.  Child.,   1914,  VIII,   163. 


698  THE  DISEASES  OF  CHILDREN 

There  are  also  occasional  vomiting  and  tympanites  and  often  firm  soap- 
stools,  but  no  special  signs  of  illness.  The  most  effective  treatment  is  a 
diminution  of  the  fat  and  an  increase  of  the  carbohydrate  element  of  the 
diet. 

2.  Dyspepsia. — This  is  also  a  mild  form  of  the  disturbance.  Its 
commonest  cause  is  an  inability  to  assimilate  carbohydrates,  with  a 
consequent  fermentation  of  these  in  the  intestine,  and  resulting  increase 
of  peristalsis,  with  diarrhea.  This  fermentation  of  the  carbohydrates 
prevents  the  proper  absorption  of  the  fat,  which  then  appears  in  the  stools. 
Increase  in  the  amount  of  food  produces  loss  of  weight  (paradoxical  reac- 
tion). The  symptoms  consist  in  the  same  failure  to  gain  weight  seen 
in  disturbance  of  balance,  together  with  the  occurrence  of  diarrhea. 
There  is  loss  of  appetite,  vomiting,  tympanites  and  colic.  The  stools 
are  thin,  green,  frothy,  and  contain  mucus  and  white  lumps  composed  of 
fat  and  bacteria.  Treatment  is  best  carried  out  by  giving  human  milk. 
In  the  absence  of  this  the  carbohydrates  should  be  reduced  after  a  brief 
period  of  fasting.  Often  the  employment  of  some  other  sugar  than  that 
of  milk  is  successful;  cane  sugar  and,  still  better,  dextrine-maltose  prepa- 
rations being  less  liable  to  ferment.  The  fat  also  should  be  reduced. 
Buttermilk  is  often  of  service.  He  regards  "casein-milk"  as  one  of  the 
best  of  foods  for  the  condition.  (See  p.  148.)  Too  long  a  continuance 
of  under-feeding  must  be  avoided. 

3.  Decomposition.— By  this  term  is  indicated  a  loss  of  the  constituents 
of  the  body;  a  decomposition.  It  is  one  of  the  severe  forms  of  nutritional 
disorder,  the  equivalent  of  the  condition  ordinarily  described  as  infan- 
tile atrophy,  or  marasmus.  It  depends  upon  a  very  decided  loss  of 
digestive  power.  There  is  a  great  intolerance  for  fat  and  carbohydrate. 
The  symptoms  consist  in  gradual  and  progressive  loss  of  weight,  and  the 
infant  has  the  ordinary  appearances  of  marasmus  elsewhere  described 
(page  610).  The  temperature  is  subnormal,  the  abdomen  distended, 
the  color  pale,  the  child  is  at  first  excited  but  later  torpid,  the  movements 
of  the  bod}^  are  slow,  and  the  appetite  is  often  large.  The  stools  are  not 
well  digested,  and  may  be  either  solid  or  diarrheal,  and  often  contain  an  ex- 
cess of  fat.  The  pulse  is  slow;  the  respiration  often  irregular.  There  is  a 
very  decided  paradoxical  reaction,  more  marked  than. in  the  preceding 
forms;  any  increase  in  the  amount  of  food  given  being  at  once  followed  by 
decrease  of  weight.  The  system  is  very  susceptible  to  infection  and  other 
morbid  influences,  and  fever  is  produced  readily  from  such  causes  or 
from  an  increase  in  the  food.  Edema  and  cyanosis  develop  readily. 
The  prognosis  is  on  the  whole  unfavorable,  although  under  suitable 
management  recovery  may  occur,  if  the  condition  is  not  too  far  advanced. 
Sudden  death  is  not  uncommon,  while  other  children  die  with  the  symp- 
toms of  the  alimentary  intoxication  to  be  described.  Treatment  consists 
in  stopping  the  abnormal  changes  going  on  in  the  food  and  giving  suffi- 
cient suitable  nourishment.  This  can  best  be  accomplished  by  feeding 
with  human  milk;  often  preferably  from  a  bottle  and  diluted.  If  human 
milk  cannot  be  obtained,  the  most  suitable  foods  are  skimmed  milk  or 
buttermilk  fortified  by  a  starchy  addition;  and  especially  casein-milk. 
The  last  is  claimed  to  be  of  particular  value  on  the  ground  that  by  the 
removal  of  the  milk-sugar  which  is  contained  in  the  whey  the  tendency 
to  fermentation  is  lessened. 

4.  Alimentary  Intoxication. — This  is  a  threatening  condition  of  food- 
intolerance  developing  as  a  later  stage  after  that  of  dyspepsia  or  of 
decomposition.     The  disorder  is   probably   an  acidosis.     The   cause   is 


THE  FINKELSTEIN  CLASSIFICATION  699 

the  administration  of  food  much  above  the  tolerance  of  the  child,  and 
the  consequent  severe  disturbance  of  metabolic  processes.  Food  rich 
in  whey  or  carbohydrate  is  especially  prone  to  produce  the  condition; 
but  excess  of  fat  is  toxic  also.  The  first  symptom  is  fever;  proven  to  be 
alimentary  in  that  it  ceases  promptly  when  food  is  withdrawn,  unless  some 
complicating  infection  is  present.  The  degree  of  fever  varies  with  the 
severity  of  the  case.  It  may  be  the  only  early  symptom  and  be  moderate 
or  high,  or  in  cases  following  decomposition  there  may  be  no  elevation  of 
temperature.  With  the  fever  may  be  diarrhea  and  loss  of  weight.  In 
well-marked  cases  of  the  fully  developed  condition  nervous  and  mental 
disturbances  are  among  the  most  prominent  symptoms.  There  may  be 
only  lassitude  and  sleeplessness,  or  there  may  be  deep  coma  with  sunken 
eyes,  or  convulsions  or  other  meningeal  symptoms.  Vomiting  is  common, 
often  severe  and  sometimes  violent;  and  when  there  is  diarrhea  the  stools 
are  alkaline,  but  variable  in  other  characteristics.  Loss  of  weight  is 
very  rapid  on  account  of  the  removal  of  liquid  from  the  system,  and 
the  skin  becomes  .shrivelled,  the  fontanelle  sunken,  and  the  muscles  of 
the  trunk  and  hmbs  often  painfully  contracted.  The  same  loss  of  fluid 
probably  accounts  for  the  ready  development  of  collapse.  The  urine 
contains  albumin  and  often  hyaline  and  granular  casts,  and  there  may  be 
alimentary  glycosuria.  There  is  always  leucocytosis  even  up  to  30,000. 
The  prognosis  depends  upon  the  previous  condition  and  the  severity  and 
duration  of  the  symptoms;  but  on  the  whole  is  not  unfavorable  in  cases 
developing  acutely  and  treated  promptly,  and  not  antedated  by  severe 
decomposition.  The  treatment  consists  in  the  immediate  cessation  of 
all  feeding  and  the  administration  in  some  way  of  large  amounts  of  water, 
adding  saccharin  if  sweetening  is  necessary.  Starvation  cannot  be 
long-continued  in  marantic  cases.  In  returning  to  food,  human  milk 
should  be  obtained  if  possible;  if  not,  fat  and  sugar  should  be  at  first 
avoided.     Casein-milk  and  buttermilk  are  recommended. 

The  advantage  of  Finkelstein's  classification  is  that  it  tends  to  a 
unification  of  many  gastrointestinal  disorders,  the  division  of  which  into 
separate  entities  has  long  been  a  problem  without  satisfactory  solution. 
Among  its  disadvantages  is  its  assumption  as  finally  proven  of  something 
which  is  by  no  means  universally  admitted.  Those  who  have  long  fol- 
lowed the  increasing  purification  of  the  milk-supply,  as  connected  with 
the  lessening  morbidity  and  mortality  of  infants  during  hot  weather, 
find  it  difficult  to  admit  that  bacteria  plaj'  as  small  a  part  in  the  produc- 
tion of  summer-diarrhea  as  Finkelstein's  claims  assign  to  them.  There 
are,  also,  sufficient  grounds  based  on  experimental  work  to  render  it  prob- 
able that  in  many  cases  a  change  in  the  character  of  the  food  does  good 
by  militating  against  the  growth  of  certain  harmful  species  of  bacteria 
in  the  intestinal  canal,  whether  or  not  these  possess  any  distinct  infectious 
power.  Then,  too,  the  study  of  metabohsm  and  its  relation  to  the  charac- 
ter of  the  food  given  is  a  subject  undergoing  constant  modification  as  new 
facts  are  discovered,  and  the  results  obtained  are  far  from  being  uniform. 
It  is  in  accord  with  the  statement  of  the  opening  part  of  this  ciiapter  to 
say,  that  in  the  present  state  of  our  knowledge  it  is  as  impossible  to  clas- 
sify the  disorders  of  the  stomach  and  intestine  on  a  purely  metal)olic 
theory  as  it  is  upon  a  purely  bacteriological  one.  On  this  account  I 
have  attempted  to  adopt  provisionally,  and  as  a  matter  of  convenience, 
a  classification  })ase(l  chiefly  upon  the  clinical  manifestations  as  con- 
nected with  the  diff'erent  regions  of  the  gastrointestinal  tract;  modified 
by  what  we  may  believe  we  certainly  know  of  the  respective  action  of 
the  food-ingredients  anrl  of  the  bacteria. 


700  THE  DISEASES  OF  CHILDREN 

VOMITING 

Vomiting,  although  in  no  sense  a  disease  itself  but  a  symptom  of 
many  other  affections,  is  so  common  in  infancy  and  childhood  that  a 
review  of  some  of  the  causes  and  varieties  is  in  place.     (See  also  p.  206.) 

1.  One  of  the  most  troublesome  forms  seen  in  infancy  is  due  to 
overloading  of  the  stomach.  This  may  occur  simply  from  overfilling 
of  the  organ  in  a  child  in  other  respects  healthy.  At  first  it  is  a  mere 
regurgitation  of  the  excess  of  food  taken;  is  harmless  in  itself;  and  is  un- 
attended by  evidences  of  nausea,  such  as  sudden  cessation  of  crying, 
pallor  about  the  mouth,  and  the  like.  If  the  overloading  is  persisted  in 
the  condition  may  soon  become  worse,  an  acute  or  chronic  dyspeptic  con- 
dition develops,  and  vomiting  empties  the  stomach  more  or  less 
completely. 

2.  What  may  be  called  nervous  vomiting  or  habit-vomiting  is  an  exceed- 
ingly intractible  and  common  form  seen  in  many  infants.  In  such  cases 
the  shghtest  excitement  may  produce  vomiting;  such  as  crying,  sudden 
movement  of  the  infant  by  the  mother  or  nurse,  or  sometimes  the  mere 
psychic  stimulation  connected  with  taking  food,  laughing,  or  even  smil- 
ing. It  is  on  account  of  the  mental  influence  that  vomiting  may  be 
almost  or  quite  absent  during  the  sleeping  hours,  but  may  occur  after  every 
feeding  during  the  daytime.  Doubtless  a  more  or  less  dyspeptic  state  is 
present  in  most  of  these  cases.  A  very  similar  condition  is  often  seen  in 
older  children,  in  which  vomiting  becomes  a  habit,  and  anger  or  other 
emotion  may  readily  produce  it.  Such  children  vomit  when  any  medi- 
cine is  given  which  has  an  unpleasant  taste,  and  sometimes  if  the  ad- 
ministration of  even  an  agreeably  tasting  medicine  is  attempted,  or  if 
food  is  urged  of  which  they  are  not  fond.  Many  of  these  children  seem  to 
have  the  power  of  vomiting  at  will,  and  take  advantage  of  this  to  the 
overthrow  of  all  discipline.  In  other  instances  the  vomiting  is  dependent 
upon  a  neurotic  or  hysterical  condition.  Some  cases  of  this  nature 
vomit  especially  in  the  morning,  before  or  after  breakfast,  the  occurrence 
being  connected  with  the  excitement  or  overwork  of  school-life.  Still 
another  cause  of  nervous  vomiting  depends  upon  a  disturbance  of  the 
equilibrium  of  the  body,  as  in  swinging,  sea-travel,  or  railroad-journeys. 

3.  Organic  nervous  diseases  are  frequently  attended  by  vomiting 
dependent  upon  actual  pathological  changes  outside  of  the  stomach. 
This  is  especially  true  of  meningitis  and  of  intracranial  tumors  and  abscess. 
It  is  often  the  earliest  symptom  noticed  and  is  sometimes  very  persistent, 
and  often  violent  and  "projectile"  in  character.  The  other  evidences  of 
intracranial  disease  soon  develop. 

4.  Vomiting  is  nearly  always  present  in  acute  gastric  dyspepsia,  due  to 
the  ingestion  of  indigestible  food,  whether  in  infants  or  older  children. 
It  may  come  on  immediately  after  eating,  especially  in  infancy,  but  usu- 
ally occurs  after  some  hours,  the  contents  of  the  stomach  then  showing 
evidence  of  disordered  digestion.  It  is  preceded  by  nausea,  faintness,  loss 
of  appetite,  and  sometimes  fever,  and  may  continue  after  the  first  empty- 
ing of  the  stomach;  mucus  and  finally  bile  appearing  in  the  vomited 
matter. 

5.  Chronic  gastritis  is  attended  by  the  frequent  vomiting  of  food  which 
has  remained  too  long  in  the  stomach  and  has  undergone  decomposition, 
or  of  merely  an  acid,  watery  hquid. 

6.  Acute  infectious  diseases  are  very  commonly  ushered  in  by  vomit- 
ing. This  is  especially  characteristic  of  scarlet  fever  and  pneumonia,  but 
is  also  true  of  malaria,  typhoid  fever,  poliomyelitis  and  other  infectious 


RECURRENT  VOMITING  701 

disorders.     It  probably  is  caused  by  the  direct  action  of  the  poison  of 
the  disease. 

7.  Toxic  vomiting  may  be  produced  in  various  ways.  It  is  seen  for 
instance  in  recurrent  or  cycHc  vomiting,  being  dependent  upon  some 
poison  in  the  blood.  In  a  similar  way  uremia  is  often  productive  of 
vomiting.  Poisonous  substances  introduced  into  the  stomach  may  cause 
vomiting  by  direct  irritation  of  the  organ  or,  as  in  the  case  of  contami- 
nated milk,  by  the  actual  absorption  of  poisonous  material  produced  by 
the  changes  which  have  taken  place  in  the  food.  The  vomiting  which 
often  occurs  in  the  later  course  of  diphtheria,  typhoid  fever  and  other 
infectious  diseases  is  probably  toxic  or  septic  in  nature. 

8.  Vomiting  after  cough  is  seen  especially  in  pertussis,  but  may  occur 
after  severe  coughing  from  any  cause. 

9.  Obstructive  vomiting  is  observed  in  several  conditions.  One  of  the 
most  frequent  causes  is  intestinal  obstruction,  especially  intussusception. 
It  is  attended  by  constipation,  prostration,  and  in  intussusception  by 
bloody  mucous  evacuations.  Rarely  the  vomited  matter  becomes 
fecal  later  in  the  disease.  Congenital  obstruction  of  the  duodenum  or 
pylorus  is  a  cause  of  obstinate  vomiting  in  early  infancy. 

10.  Appendicitis  is  commonly  productive  of  vomiting  attended  by 
severe  abdominal  pain  early  in  the  attack.  Later  it  may  recur  from  the 
development    of    septic    poisoning. 

11.  General  'peritonitis  from  any  source  is  nearly  always  attended  by 
vomiting.  It  is  accompanied  by  the  other  signs  of  the  disease  and  is  due 
either  to  sepsis  or  to  paralysis  of  peristalsis,  which  consequently  produces 
practically  an  intestinal  obstruction. 

12.  Passive  congestion  of  the  stomach,  such  as  occurs  in  severe  forms  of 
heart-disease,  is  often  attended  by  vomiting  with  evidences  of  chronic 
indigestion. 

13.  Reflex  vomiting  may  depend  upon  many  causes,  as  the  presence  of 
worms  in  the  intestinal  canal,  the  putting  of  its  fingers  by  the  infant  into 
its  mouth  and  throat,  and  the  like. 

In  every  case  of  vomiting  the  important  and  often  difficult  matter  is 
to  determine  the  cause.     Treatment  is  then  that  indicated  for  this. 

RECURRENT^VOMITING 
(Cyclic  Vomiting) 

This  type  of  vomiting  has  symptoms  so  peculiar  and  characteristic 
that  it  may  properly  be  described  as  an  independent  disease.  Cases  of 
this  nature  had  been  reported  earher,  but  the  first  important  description 
of  the  condition  appears  to  have  been  by  Gruere,^  and  it  has  only  in  recent 
years  been  carefully  studied,  especially  in  this  country  and  in  France. 
The  title  ''recurrent"  is,  I  think,  to  be  preferred  to  "cyclic,"  since  the 
latter  implies  a  certain  regularity  which  is  not  a  characteristic  of  the 
disease. 

Etiology  and  Pathogenesis. — This  has  been  much  discussed,  yet 
is  but  little  understood.  The  first  attack  usually  develops  in  early  child- 
hood; occasionally  in  infancy.  Sex  exercises  no  important  influence.  A 
highly  developed  nervous  organization  seems  to  predispose,  but  the 
disease  is  by  no  means  confined  to  such  children.  It  is  noteworthj-, 
however,   that   it  occurs   nearly  always   in   private   practice.     Family 

"^  Prclicis  di's  travoaux,  de  la  soe.  mi'id.  dc  Dijon,  18H8-1S41.  Ref.,  Northrup, 
in  Granchcr  and  Coniby,  TraiK?  des  nialad.  de  I'onfance,  1904,  II,  191. 


702  THE  DISEASES  OF  CHILDREN 

history  is  without  special  influence  except  in  the  predisposition  of  chil- 
dren inheriting  a  nervously  organized  constitution.  Fatigue;  the  devel- 
opment of  some  minor  disease;  and  exposure  to  cold  or  to  fright  or  other 
emotional  disturbance,  seem  sometimes  to  precipitate  attacks.  Diet 
undoubtedly  has  some  influence,  but  the  nature  of  this  is  not  entirely 
understood,  since  although  an  alteration  of  it  seems  effectual  in  prevent- 
ing attacks  in  some  cases,  the  most  careful  regulation  is  without  result  in 
others.  The  occurrence  of  slight  premonitory  yet  distinctly  digestive 
symptoms  certainly  suggests  an  etiological  relationship. 

Various  theories  have  been  advanced  to  explain  the  pathogenesis  of 
the  disease.  One  maintained  especially  bj^  French  waiters  is  that  the 
affection  is  a  manifestation  of  the  uric  acid  diathesis,  or  ''arthritism. " 
The  production  of  vomiting  by  this  condition  is  not,  however,  as  yet 
proven.  Marfan^  and  others  in  France  have  associated  recurrent  vomit- 
ing with  acetonemia  and  designated  it  "acetonemic  vomiting,"  on  the 
ground  that  acetone  is  so  constantly  present  in  the  urine.  There  is  no 
evidence,  however,  as  Marfan  admits,  that  acetonemia  produces  the 
attack,  since  acetonuria  is  seen  in  so  many  other  affections,  and  may  well 
in  this  disease  be  the  result  of  the  original  cause  or  sometimes  of  the 
starvation-process.  The  presence  of  iS-oxybutyrio  acid  in  the  urine, 
pointed  out  by  EdsalV  indicates  the  possibility  of  the  condition  being  an 
acidosis.  This  view  has  much  in  its  favor,  but  is  still  wanting  certain 
proof,  and  the  difference  between  acidosis  and  the  mere  presence  of 
acetone  bodies  in  the  urine  is  to  be  borne  in  mind.  (See  p.  635.) 
Sedgwick^  and  Mellanby*  found  a  urinary  excretion  of  creatin  at  the  time 
of  the  attack,  and  believe  this  points  to  abnormal  metabolic  changes. 
The  former  also  attributed  to  adenoids  a  powerful  etiological  influence. 
The  occasional  occurrence  of  icterus  has  led  others  to  beheve  that  the  liver 
is  at  fault  (Richardiere.)^  Comby''  thought  that  the  vomiting  depended 
in  many  instances  upon  a  chronic  appendicitis.  That  the  attacks  are 
of  hysterical  origin  has  been  maintained,  but  the  occurrence  of  fatal 
cases  with  evidence  of  renal  lesions  renders  this  unhkely,  and  certainly 
inapplicable  to  all  instances.  Snow^  believed  it  dependent  in  some  cases 
upon  an  intermittent  hyperchlorhydria.  My  own  experience  leads  me  to 
the  opinion  that  the  disease  is  a  toxic  neurosis  occurring  in  those  especially 
predisposed  to  it,  and  that  the  outbreak  depends  upon  the  gradual  heaping 
up  in  the  system  of  a  poison  of  a  nature  as  yet  undetermined,  yet  it 
may  be  an  acid  arising  possibly  in  the  digestive  tract  or  more  probably 
in  disordered  metabolic  processes,  and  that  inability  to  assimilate  the  fat 
of  the  diet  is  the  direct  cause  in  many  instances.  That  some  poison  is  at 
work  is  certainly  indicated  by  the  degenerative  changes  in  the  kidneys 
and  other  internal  organs  sometimes  found  in  fatal  cases. 

Symptoms.^ — ^The  attack  may  commence  suddenly  or  may  be  preceded 
for  12  or  more  hours  by  such  manifestations  as  coated  tongue,  constipation, 
malaise,  irritability,  abdominal  discomfort,  and  loss  of  appetite.  Vomit- 
ing then  begins,  at  first  of  the  food  ingested;  later  merely  serous  or  mucous 
or  finally  bilious,  or  sometimes  brownish  or  blood-stained.  The  vomiting 
is' of teUj forceful,  with  much  retching,  and  occurs  whenever  anything 

1  Bull.  soc.  do  pediat.,  1905,  VII,  41. 

2  Amer.  Journ.  Med.  Sci.,  1903,  CXXV,  629. 

3  Amer.  Journ.  Dis.  Child.,  1912,  111,  209. 
^Lancet,  1911,  II,  8. 

6  Ann.  do.  mod  et.  de  chir.  inf.,  1905,  IX,  150. 
«  Arch,  de  m6d.  des  enf.,  1905,  VIII,  741. 

7  Amer.  Journ.  Med.  Sci.,  1904,  CXXVIII,  966. 


RECURRENT    VOMITING  703 

whatever  is  swallowed,  or  even  without  this  with  varying  frequency'; 
sometimes  in  severe  cases  as  often  as  every  half  hour.  There  is  little 
or  no  elevation  of  temperature;  often  abdominal  pain;  and  occasionally 
tenderness,  obstinate  constipation,  urgent  thirst,  scaphoid  abdomen  or 
sometimes  tympanites,  and  in  some  cases  headache.  The  pulse  is 
sometimes  rapid  and  weak,  sometimes  slow  or  intermittent.  As  the 
attack  continues  the  coated  tongue  becomes  dry  and  brown;  the  prostra- 
tion extreme;  there  is  an  anxious  expression  of  face;  the  ej^es  are  sunken; 
there  is  an  odor  of  acetone  on  the  breath;  the  urine  is  scanty  and  some- 
times albumin  and  /3-ox3^butyric  acid  appear  in  it.  Acetone  is  constantly 
present  later  in  the  attack  and  in  some  cases  at  the  outset  also. 

Course  and  Prognosis.^ — The  attack  lasts  2  to  4  days  and  some- 
times longer,  and  recover}^  from  it  is  usually  rapid.  The  bowels  open  of 
their  own  accord  or  yield  to  purgatives;  appetite  returns;  vomiting  grows 
rapidly  less  frequent,  and  in  a  few  days  no  symptoms  remain  except  the 
emaciation  and  loss  of  strength,  which  soon  disappear.  The  prognosis 
is  on  the  whole  good.  In  spite  of  the  extreme  prostration  not  infre- 
quently present,  recovery  generally  takes  place.  This  is  not,  however, 
without  exception.  I  have  reported^  2  very  typical  cases  terminating 
fatally  with  evidences  of  nephritis,  and  I  have  seen  another  ending  in 
death,  and  still  another  in  which  the  great  debility  resulted  in  thrombosis 
of  the  arterj^  of  one  leg  with  consequent  gangrene  and  loss  of  the  foot  by 
amputation.  A  number  of  other  fatal  cases  are  on  record  in  medical 
literature.  There  is  always  a  recurrence  of  attacks  at  irregular,  or  occa- 
sionally somewhat  regular,  intervals  usually  of  several  months,  and  this 
may  continue  throughout  several  years,  although  as  puberty  is  ap- 
proached there  is  a  tendency  for  the  attacks  to  cease.  In  some  instances, 
as  in  those  reported  by  Rachford,-  the  attacks  of  vomiting  have  been 
replaced  by  migraine  later  in  life. 

Diagnosis. — This  often  presents  many  difficulties  unless  there  is  a 
history  of  previous  attacks  of  a  similar  nature.  Even  with  this  it  is  im- 
portant to  make  a  most  careful  examination  of  the  body,  including  the 
urine,  to  eliminate  the  presence  of  other  causative  conditions.  The 
obstinate  constipation  may  suggest  intestinal  obstruction,  and  I  have  seen 
cases  in  which  the  differential  diagnosis  was  most  difficult.  There  is 
seldom,  however,  severe  abdominal  pain  in  recurrent  vomiting,  and  in  the 
case  of  intussusception  there  are  characteristic  distinguishing  symptoms. 
Yet  cases  showing  typical  symptoms  of  recurrent  vomiting  have  been 
found  at  autopsy  to  depend  upon  obstruction  of  some  sort,  as  at  the  py- 
lorus (Russell)^  or  in  the  duodenum  (Gordon)."*  Appendicitis  usually 
has  less  severe  vomiting  and  is  attended  by  localized  tenderness  and  a 
greater  degree  of  pain,  together  with  fever.  Yet  I  have  known  of  opera- 
tion being  performed  on  the  theory  that  the  vomiting  depended  upon  a 
chronic  appendicitis.  Acute  indigestion  has  often  the  history  and  the 
evidence  of  indiscretion  in  diet  and  the  vomiting  is  of  shorter  duration. 
Acute  febrile  diseases  with  an  onset  with  vomiting  are  generally  soon  dis- 
tinguished by  the  development  of  other  symjitoms.  Tuberculous  menin- 
gitis or  other  serious  disorder  of  the  brain  has,  it  is  true,  vomiting  of  a 
suggestive  forceful  character,  l)ut  the  nature  of  the  other  symptoms 
eventually  eliminates  recurrent  vomiting  fioiii  consideration.     A^ephritis 

'  Trans.  A.sso(;.  of  Amor.  Phvs.,1900,  XV,  Ki.     Aiucr.  .luuin.  Med.  Sci.,  1900,  Nov. 

2  Archives  of  Pod.,  1898,  XV,  (K)7. 

'  PrO(!.  Roval  Acad,  of  Med.,  1909-10.     Dis.  of  Cliild.,  78. 

*  Brit.  Med.  Journ.,  1906,  11,  80(). 


704  THE  DISEASES  OF  CHILDREN 

may  produce  uremic  attacks  with  severe  vomiting.  Careful  examination 
of  the  urine  will  settle  the  question. 

Treatment.^ — ^In  cases  where  premonitory  symptoms  show  them- 
selves the  attack  may  sometimes  be  aborted  by  stopping  all  food  and 
by  procuring  a  very  free  evacuation  of  the  bowels  by  purgatives,  such  as 
Rochelle  salts,  citrate  of  magnesia,  or  calomel.  Enemata  do  not  answer, 
since  it  is  not  the  mere  unloading  of  the  bowel  which  is  desired,  bat  the 
elimination  of  poisonous  substances  from  the  blood.  If  vomiting  has 
commenced,  a  tentative  trial  of  purgatives  should  be  made,  but  this 
should  not  be  persisted  in  if  the  medicine  is  rejected.  No  food  or  drug 
of  any  sort  should  then  be  given  by  the  mouth.  The  child  should  be  kept 
as  quiet  as  possible  in  bed.  To  relieve  the  distressing  thirst,  small 
pieces  of  ice  may  be  placed  in  the  mouth,  but  this  should  be  limited  as 
much  as  possible,  since  the  irritability  of  the  stomach  is  very  liable  to 
be  increased  in  this  way.  If  the  case  is  prolonged,  rectal  feeding  may  be 
tried ;  and  where  the  character  of  the  pulse,  the  appearance  of  the  patient, 
or  the  scanty  urination  makes  it  evident  that  there  is  need  of  liquid  in 
the  tissues,  enteroclysis  may  be  given,  or  hypodermoclysis  employed  if 
necessary.  The  only  form  of  medicinal  treatment  in  my  experience  which 
offers  much  hope  of  checking  the  vomiting  is  the  hypodermic  adminis- 
tration of  morphine  in  full  doses.  The  relief  is  sometimes  remarkably 
prompt  and  lasting,  and  I  believe  I  have  seen  it  without  question  save 
life.  In  other  cases,  however,  it  is  not  of  much  benefit.  Bromides  and 
chloral  may  be  tried  by  the  bowel,  but  are  usually  unavailing.  As  the 
attack  subsides  careful  return  to  food  may  be  made,  employing  such  arti- 
cles as  broth,  barley  water,  albumen  water,  and  equal  parts  of  skimmed 
milk  and  lime  water. 

Effort  should  be  made  in  the  intervals  to  prevent  the  recurrence  of 
attacks.  On  the  theory  that  the  disease  was  an  acidosis,  EdsalP  and 
Pearson^  recommended  keeping  the  child  on  full  doses  of  bicarbonate  of 
soda,  }y^  to  }''2  dram  (0.97  to  1.94)  3  times  a  day,  the  amount  given  being 
increased  greatly  should  any  prodromal  symptoms  appear.  I  have 
known  this  treatment  to  appear  very  efficacious,  but  to  fail  in  other  in- 
stances. Care  should  be  taken  that  the  bowels  are  open  daily,  and  at 
intervals  of  a  week  or  two  a  freely  acting  purgative  should  be  adminis- 
tered. Excitement  and  undue  fatigue  should  be  avoided.  The  diet 
should  be  digestible  and  simple,  but  of  just  what  nature  we  cannot  yet 
determine  until  the  cause  of  the  disease  is  better  understood.  Limiting 
the  amount  of  fat  and  increasing  that  of  the  carbohydrate  should  cer- 
tainly be  tried,  on  the  assumption  that  the  disease  may  be  due  to  an 
acidosis. 

GASTRALGIA 

Gastralgia,  like  vomiting,  is  a  symptom  of  various  conditions.  In 
the  broader  sense  of  pain  in  the  epigastrium,  not  necessarily  arising  in  the 
stomach,  it  is  common  and  may  be  the  result  of  acute  gastric  indigestion, 
spinal  caries  with  pain  conducted  along  the  nerves  of  the  abdominal  wall, 
malaria,  renal  cohc,  appendicitis,  pneumonia,  gastric  ulcer,  diaphragmatic 
pleurisy  and  other  causes.  In  some  children  of  delicate  constitution  or 
highly  neurotic  organization  there  may  occur  a  true  nervous  gastralgia, 
apparently  of  a  neuralgic  nature,  due  to  many  diverse  agencies,  such  as 
exposure,  fatigue,  and  emotional  disturbances.     This  is  more  common  in 

1  Loc.  cit. 

2  Arch,  of  Pediat,  1903,  XX,  505. 


ANOREXIA  705 

childhood  than  in  infancy.  In  the  milder  cases  the  pain  is  slight  and  of 
short  duration;  in  the  more  severe  it  may  be  continuous  and  so  intense 
that  prostration  and  faintness  are  present  and  perforation  may  be  sus- 
pected. In  infancy  symptoms  may  be  produced  which  are  apparently 
those  of  intestinal  colic,  but  which  are  reheved  b}^  the  eructation  by  the 
patient  of  gas  from  the  stomach,  thus  indicating  the  true  nature  of  the 
affection. 

A  careful  study  of  the  various  possibilities  should  be  made  in  order 
to  reach  a  correct  diagnosis  of  the  form  of  gastralgia  present.  In  the  way 
of  treatment,  the  cause  must  be  sought  for  and  removed  if  possible.  In 
those  cases  in  which  the  pain  appears  neuralgic,  or  due  to  an  accumula- 
tion of  gas  in  the  stomach,  treatment  during  the  attack  consists  in  con- 
finement to  bed;  abstinence  from  food;  hot  applications  to  the  abdomen, 
such  as  hot  water  bags,  stupes,  or  mustard  plasters;  the  administration 
of  a  carminative  such  as  ginger,  oil  of  cloves,  best  combined  with  spirits 
of  chloroform,  or  with  milk  of  asafetida  or  compound  spirits  of  ether; 
and  if  necessary  the  giving  of  an  opiate.  Between  the  attacks  efforts 
must  be  made  to  improve  the  general  health  and  to  correct  any  faults  of 
diet.  The  best  results  are  sometimes  obtained  by  the  administration  of 
quinine  or  arsenic. 

ANOREXIA 

This  is  a  symptom  common,  in  a  moderate  degree,  to  a  great  number 
of  diseased  states,  and  is  oftenest  of  brief  duration.  All  acute  febrile 
disturbances  are  liable  to  be  accompanied  by  it,  and  all  acute  cases  of 
gastric  indigestion  have  it  well-developed.  Anorexia  of  a  more  chronic 
nature  is  dependent  upon  various  causes.  Some  instances  of  chronic 
intestinal  indigestion  in  older  children  exhibit  it  to  a  decided  degree. 
In  other  cases  a  child  is  fed  so  often  or  so  largely  that  it  is  impossible  for 
the  appetite  to  be  good;  there  being  no  opportunity  to  grow  hungry. 
At  times  the  anorexia  is  in  reality  fictitious,  appetite  being  in  no  way 
actually  disturbed,  but  food  being  refused  on  account  of  pain  produced 
by  the  effort  to  take  it.  This  is  seen  in  various  disorders  of  the  mouth 
and  throat.  There  is  a  group  of  cases  in  which  anorexia  is  by  far  the 
most  prominent  symptom,  often  being  very  persistent  and  giving  the 
parents  much  anxiety.  It  is,  namely,  of  frequent  occurrence  for  an 
infant,  who  has  previously  taken  food  well,  to  empty  but  partially  or 
entirely  refuse  one  or  more  bottles  daily,  and  to  continue  in  this  condition 
for  weeks.  There  is  no  apparent  alteration  of  any  kind  in  the  general 
health  or  spirits,  except  that  constipation  is  a  very  common  attendant. 
In  some  of  these  cases  a  constant  error  in  diet  may  be  discovered.  In 
others  no  such  cause  can  be  found.  Yet  the  condition  is  almost  certainly 
a  form  of  gastrointestinal  indigestion  of  which  the  anorexia  is  the  only 
apparent  symptom. 

In  older  children  anorexia  of  this  sort  is  even  more  common.  Many 
such  seem  never  to  care  about  eating,  and  every  meal-time  is  a  struggle 
on  the  part  of  the  parents  to  persuade  the  child  to  take  food.  A  cause 
can  often  be  discovered  for  the  trouble.  In  some  cases  it  is  the  absence 
of  sufficient  out-of-door  life  and  exercise.  In  others  small  amounts  of 
iood  are  l)eing  frequently  given  to  the  child  between  meals,  and  this  is 
often  of  an  entirely  unsuitable  nature,  such  as  sweetmeats,  cake,  and  the 
Uke;  and  as  a  natural  result  the  digestive  processes  are  interfered  with  and 
anorexia  follows.  In  certain  cases  it  is  associated  with  constii)ation. 
In  still  others  the  condition  is  truly  constitutional,  tlie  child  being  from  birth 

45 


706  THE  DISEASES  OF  CHILDREN 

a  light  eater  without  the  normal  desire  for  food.  In  some  instances  of 
this  sort  a  very  thorough  assimilation  of  the  food  takes  place,  and  the 
health  does  not  suffer;  but  in  others  the  child  is  always  more  anemic 
and  less  well-nourished  than  should  be  the  case.  The  loss  of  health  may 
be  the  result  of  the  loss  of  appetite;  but  in  many  instances  the  anorexia 
is  only  one  of  the  manifestations  of  the  general  delicate  state  of  health 
which  is  characteristic  of  the  patient,  and  which  is  in  many  cases  inherited 
and  often  cannot  be  satisfactorily  overcome.  Finally,  in  certain  cases 
presently  to  be  described  the  anorexia  may  be  purely  nervous  (Anorexia 
Nervosa) . 

Treatment. — The  treatment  of  these  cases  of  habitual  anorexia 
is  often  most  perplexing.  It  is  primarily  that  of  the  cause  when  this  can 
be  discovered.  Careful  attention  should  be  paid  to  the  condition  of  the 
bowels  and  any  tendency  to  constipation  overcome.  The  hygiene  of  the 
patient  must  be  considered  and  an  out-of-door  life  prescribed.  For  older 
children  cool  morning  baths  may  be  employed.  Massage  may  be  of 
service  and  temporary  change  of  climate,  such  as  a  visit  to  the  seashore 
or  the  mountains,  may  be  most  efficacious.  Regulation  of  the  diet  is 
most  important.  All  eating  between  meals  should  be  positively  for- 
bidden. An  infant  who  refuses  its  bottle  had  better  not  be  fed  until  the 
next  usual  hour  for  feeding  arrives.  In  the  acute  cases  the  reduction 
by  the  child  itself  of  the  amount  of  food  taken  is  probably  Nature's  own 
method  of  cure  and  should  not  be  interfered  with;  and  it  is  usually  well 
to  reduce  temporarily  the  strength  of  the  food  given.  Sometimes  the 
omission  for  a  time  of  the  fat  from  the  diet  is  of  advantage;  eggs  and  whole 
milk  being  forbidden;  or  solid  food  entirely  withdrawn  for  a  season.  In 
some  cases  it  is  best  to  withdraw  from  the  diet-list  foods  which  are  satis- 
fying but  not  very  nourishing.  Thus  children  who  have  the  appetite 
entirely  satisfied  by  a  bowl  of  clear  broth,  and  who  will  eat  nothing  after 
it,  should  have  no  such  food  given. 

As  far  as  medication  goes  I  have  had  the  best  results  from  the  admin- 
istration of  an  alkaline  bitter  tonic  before  meals,  such,  as  the  combination 
of  tincture  of  nux  vomica,  tincture  of  gentian  and  bicarbonate  of  soda, 
in  doses  suitable  to  the  age.  Occasionally  a  mineral  acid  is  more  effica- 
cious given  after  meals.  The  administration  of  sherry,  port  wine,  or 
whiskey  3  times  a  day  is  often  of  benefit,  care  being  taken  in  older 
children  that  no  fondness  for  alcohol  is  developed.  The  addition  of  a 
bitter  tonic  to  the  stimulant  tends  to  prevent  this.  With  the  tonic 
treatment  should  be  combined  purgation  every  5  to  7  days,  with  the  in- 
tention of  removing  toxic  material  from  the  circulation.  This  is  in  addi- 
tion to  the  daily  regulation  of  the  bowels  referred  to. 

Anorexia  Nervosa. — This  form  of  loss  of  appetite  must  receive  a, 
short  separate  consideration.  It  is  always  of  purely  nervous  origin  and 
is  in  some  instances  a  hysterical  manifestation.  The  disease  as  occur- 
ring in  children  has  been  ably  reviewed  by  Forchheimer.^  The  simplest 
form  is  that  developing  under  the  influence  of  emotional  excitement. 
Pleasurable  anticipation,  as  of  a  visit  to  the  theater  or  the  circus,  may 
remove  for  a  time  all  desire  for  food.  The  excitement,  for  instance,  of 
the  first  going  to  school,  or  the  influence  of  anxiety  or  grief,  may  diminish 
or  abolish  the  appetite  for  da3^s  or  longer.  It  is  the  more  chronic  cases, 
however,  which  give  trouble  to  the  physician.  In  this  category  belong 
some  of  the  instances  already  referred  to  of  persistently  poor  appetite 
in  the  period  of  childhood.     The  repugnance  to  food  may  be  so  great 

1  Archiv.  of  Pediat.,  1907,  XXIV,  801. 


STENOSIS  OF   THE  PYLORUS  707 

that  insistence  upon  eating  beyond  a  certain  amount  results  in  the  child 
vomiting  what  it  has  taken.  An  element  of  hysteria  plaj^s  a  large  part 
in  many  of  the  cases.  A  child  who  has  acquired  a  reputation  for  having 
no  appetite,  subconsciously  feels  obliged  to  live  up  to  this.  Conse- 
quently the  anxious  urging  of  food  upon  such  a  subject,  or  the  remarks 
made  in  his  presence  by  the  parents  regarding  the  lack  of  appetite,  tend 
to  fix  firmly  in  the  child's  mind  the  unwilhngness  to  eat.  I  have  pre- 
vioush'  reported  cases  of  this  nature.  ^  Imitation,  too,  plays  an  important 
role,  and  if  other  members  of  the  family  eat  but  little  and  openly  express 
dislike  for  certain  articles  of  diet  the  nervously  susceptible  child  is  very 
liable  to  do  the  same  thing.  In  older  children  this  hysterical  anorexia 
may  become  a  very  serious  menace  to  health  (Forchheimer),^  but  even  in 
infancy  the  influence  of  the  idea  upon  the  appetite  is  much  more  frequent 
than  ordinarily  supposed  and  may  reach  a  threatening  degree.  In  a  case 
previously  reported^  an  infant  of  21  months  refused  all  nourishment  but 
breast-milk,  which  had  become  insufficient.  After  a  month  of  effort 
gavage  3  times  a  day  was  ordered  and  was  required  for  a  period  of  6 
months.  This  anorexia  apparently  depended  upon  fear  of  anything 
given  from  a  spoon  or  glass,  the  fear  dating  from  an  attack  of  illness 
at  9  months,  when  medicine  had  to  be  administered  in  this  way. 

Treatment. — The  treatment  of  anorexia  nervosa  depends  upon  the 
case  and  requires  careful  study  by  the  physician  and  cooperation  by  the 
parents.  Certainly  all  anxious  discussion  of  the  food  in  the  presence 
of  the  patient  must  be  abandoned  and  little  apparent  notice  taken  of 
whether  the  child  eats  or  not.  A  complete  alteration  of  diet  may  be  of 
benefit.  Change  of  air  is  often  useful  and  still  more  is  change  of  scene. 
Sometimes  the  temporary  separation  of  the  child  from  the  family  is  the 
most  efficacious  method  of  treatment.  In  cases  where  the  health  is 
suffering  and  other  means  are  insufficient,  gavage  may  be  necessary 
for  a  time. 

STENOSIS  OF  THE  PYLORUS 

(Hypertrophic  Pyloric  Stenosis;  Pylorospasm) 

An  instance  of  this  condition,  the  earliest  reported,  was  by  Hezekiah 
Beardsley,*  although  its  nature  was  not  recognized  at  the  time.  Possibly 
a  still  earlier  case  is  that  described  by  Armstrong^  in  1777  as  "spasm  of 
the  pylorus."  At  least  the  autopsy  revealed  this  condition,  although 
the  case  is  described  as  one  of  "watery  gripes."  A  case  in  infancy  was 
published  by  Williams^  in  1841,  and  another  by  Siemon-Dawosky"  in  1842. 
Landerer^  in  1879  and  Maier^  in  1885  described  pyloric  stenosis  as  found 
at  autopsy  in  adults.  No  further  notice  was  taken  of  the  subject  unt il  t  ho 
contribution  of  Hirschsprung^"  in  1888.  It  is  only  in  recent  years  that  tlio 
disease  has  become  the  subject  of  much  interest,  and  has  been  lUscussetl 
in  very  many  contributions  to  medical  literature.     Undoubtedly  it  is  of 

'  New  York  Med.  Jour.,  1914,  June  (5. 

^  Loc.  cil. 

3  Arch,  of  Pediat.,  IDOS.  XXV,  321. 

*  Cases  and  Ohsciv.itioiis  hv  fli(>  Medical  Society  of  New  Haven  County  in  the 
State  of  Connoclicut,  17SS;  rcpul)lislicd  hy  Osier,  Arch,  of  Ped.,  1003,  XX,  355. 

*  An  Account  of  tlic  Disea.se.s  Most   Incident  to  Cliildren. 
»  Lond.  and  lulin.  Month.  Journ.  of  Med-  Sci.,  ISU,  23. 

"  Caspar'.s  Wochensclu-.  f.  die  Kcsanimtc  Heilkunde,  1S42,  1().">. 

*  InauR.  Dissert.,  Freihurn,  lS7n. 

9  Vircliows  .Xrchiv.,  1SS5,  CII,  413. 
'"  Jahrh.  f.  Kinderheilk.,  1888,  XXVIII,  (il. 


708  THE  DISEASES  OF  CHILDREN 

much  more  frequent  occurrence  than  ordinarily  supposed.  Ibrahim^  in 
1910  states  that  up  to  the  period  of  writing  598  cases  of  stenosis  had  been 
recorded.  Numbers  of  cases  have  since  then  been  observed,  to  such  an 
extent  that  physicians  have  ceased  reporting;  them.  I  have,  for  instance, 
observed  6  cases  within  a  httle  over  1  month. 

Pathogenesis. — The  nature  and  origin  of  the  malady  is  even  yet 
not  entirely  clear.  There  appear  to  be  certainly  two  factors  in  producing 
stenosis,  and  consequently  two  classes  of  cases,  not  however,  sharply 
distinguishable:  (1)  pylorospasm,  dependent  upon  a  spasm  of  the  mus- 
cular layer  of  the  pylorus;  (2)  congenital  hypertrophy  of  all  the  tissues, 
but  especially  the  muscular  fibres,  viz.  hypertrophic  stenosis  of  the  pylorus. 
The  first  element  predominates  in  some  cases,  the  second  in  others. 
Perhaps  a  third  factor  may  be  not  without  influence  in  completing  steno- 
sis, viz.  a  swelling  of  the  mucous  membrane  of  the  pylorus.  This  is 
supported  by  the  observations  of  Weill  and  Pehu^  who  state  that  examina- 
tion of  the  pylorus  in  cases  reported  by  them  showed  cellular  infiltration 
resulting  from  inflammation.  In  the  majority  of  the  instances,  it  is 
probable  that  a  certain  degree  of  hypertrophic  stenosis  is  present,  but 
that  the  stomach  was  at  first  able  to  overcome  this;  and  that  finally 
a  large  element  of  spasm  develops  in  addition  and  closes  the  pylorus,  while 
at  the  same  time  the  expelling  power  of  the  stomach  diminishes.  In 
other  cases  it  is  possible  that  spasm  is  the  sole  or  principal  cause.  The 
numerous  instances  of  recovery  without  operation  show  the  etiological 
importance  of  spasm,  the  contraction  relaxing  and  the  muscle  of  the 
stomach  regaining  its  normal  tone.  That  spasm  may  exist  alone  is  indi- 
cated by  the  fact  that  infants  have  exhibited  typical  symptoms  of  stenosis, 
died  suddenly  from  an  intercurrent  malady,  and  at  autopsy  disclosed  no 
pyloric  narrowing  whatever.  On  the  other  hand  the  findings  at  operation 
and  at  autopsy  demonstrate  in  most  instances  the  reality  of  actual  organic 
changes  in  the  pylorus.  That  some  degree  of  organic  change  may  be 
present  even  in  the  cases  which  recover,  or  in  those  which  have  exhibited 
no  symptoms,  has  been  shown  by  the  discovery  of  hypertrophy  of  the 
pyloric  tissues  in  individuals  dying  from  other  causes.  It  would  seem, 
indeed,  very  probable  that  more  or  less  hypertrophy  is  present  in  every 
case  of  stenosis,  even  when  by  itself  it  is  not  sufficient  to  produce  the 
symptoms. 

As  to  the  method  of  production  of  either  spasm  or  hypertrophy,  there 
is  still  nothing  certain.  Thomson^  beheved  that  the  spasm  is  primary, 
due  to  the  irritation  from  intrauterine  swallowing  of  the  liquor  amnii, 
and  that  hypertrophy  follows  this.  Some  views  would  make  the  hyper- 
trophy secondary  to  spasm  from  other  prenatal  causes;  and  others 
secondary  to  some  irritation  of  the  duodenum  and  stomach,  possibly  a 
hyperacidity.  Still  other  investigators  maintain  that  the  hypertrophy 
is  a  primary  fetal  development  and  that  spasm  is  secondary  and  produced 
by  this,  and  this  would  appear  to  be  the  most  probable  explanation. 

Etiology. — The  disease  shows  itself  in  the  first  weeks  or  even  in 
the  first  days  of  life.  A  quarter  of  the  cases  occur  in  the  first  4  days  and 
an  equal  number  from  this  time  up  to  2  weeks  of  age  (Pfaundler).* 
Very  many  more  males  are  affected  then  females.  The  majority  of 
cases  reported  have  been  observed  in  breast-fed  infants  but  this  may  per- 

1  Munchener  med.  Wochenschr.,  1910,  LVII,  1154. 

2  Arch,  de  med.  des  enf.,  1910,  XIII,  507. 

•'  S -ott.  Med.  and  Surg.  Journ.,  1897,  I,  511. 

■•  Pfaundler  and  Schlossmann,  Handbuch  der  Ivinderheilk.,  1906    II,  1.  183. 


STENOSIS  OF  THE  PYLORUS  709 

haps  be  an  accidental  occurrence.  A  family  influence  is  exceptionall}^ 
noted,  in  that  more  than  one  infant  of  the  same  parents  has  been  attacked, 
or  that  the  parents  have  suffered  from  digestive  diseases.  Disturbances 
of  digestion  in  the  infant,  including  that  resulting  from  overfeeding  or 
from  excessive  acidity,  are  among  the  assigned  causes  of  spasm;  or  pos- 
sibly reflex  influences  arising  in  distant  parts  of  the  body,  a  congenitally 
sensitive  gastric  mucous  membrane,  or  a  neuropathic  constitution  may  be 
active  in  producing  it. 

Pathological  Anatomy.— In  the  cases  exhibiting  alterations  at 
autopsy  the  pylorus  is  found  elongated,  thickened,  with  the  stiffness  of 
cartilage,  and  with  the  mucous  membrane  projecting  into  the  duodenum, 
thus  bearing  a  resemblance  to  the  appearance  of  the  uterine  cervix  in 
the  vagina.  Section  of  the  p3''lorus  shows  great  thickening  of  the  walls, 
and  the  lumen  occluded  by  this  and  by  the  swelling  of  the  longitudinal 


Fig.  241. — Hypektuophic  Pyloiuc  Steno.sis  i.n  a  Six  Weeks  Old  Infant. 
a.  Tumor;  b,  longitudinal  section,  showing  hypertrophy  of  circular  fibers  and  extremely 
narrow  lumen.     (Pisek  and  LeWald,  Arch,  of  Pediat..  1912,  XXIX,  911.) 

folds  of  the  mucous  membrane  (Fig.  241).  The  appearance  is  much 
the  same  whether  due  to  spasm  or  to  hypertrophy,  and  only  care- 
ful study,  including  a  slow  stretching  of  the  pjdorus  and  microscopical 
examination,  can  show  which  condition  is  the  principal  cause  of  the 
stricture.  If  the  organic  change  is  the  predominant  one  there  is  found 
evident  hypertrophy  of  the  muscular  layer,  especially  of  the  ciiciilar 
fibres.  Increase  of  the  longitudinal  muscular  fibres  and  of  the  thickness 
of  the  mucous  and  subcutaneous  layers  is  present  to  a  less  degree.  The 
stomach  may  be  contracted  or  both  it  and  the  esopliagus  (Hlated. 

Symptoms. — Two  classes  of  cases  have  l)ecn  described:  viz.  jn'loro- 
spasm  and  hypertrophic  stenosis  of  the  pylorus;  but  clinically  the  sj-mp- 
toms  differ  only  in  degree  and  may  be  considered  together,  especially 
since  a  combination  of  the  two  factors  is  present  in  probably  all  cases. 
Evidences  of  the  disease  may  ajipear  in  the  first  days  of  life.  This  is 
particularly  true  of  cases  tlepending  chiefly  ui)on  very  decided  hyper- 


710 


THE  DISEASES  OF  CHILDREN 


trophic  stenosis.  In  such  instances  an  apparently  perfectly  healthy  and 
well-developed  infant  a  few  days  old  begins  to  vomit  without  cause.  In 
the  majority  of  cases  the  symptoms  are  longer  delayed  and  appear  only 
after  the  child  has  been  well  for  several  weeks;  and  the  vomiting  then 
perhaps  begins  immediately  consecutive  to  a  disturbance  of  digestion. 
In  these  latter  cases  spasm  is  probably  an  important  factor.  In  either 
event  vomiting  is  at  first  entirely  uncharacteristic  and  only  occasional. 
Steadily,  however,  it  grows  more  frequent,  taking  place  after  every  inges- 
tion of  food,  either  very  promptly  or  after  a  delay  of  some  hours,  all  or 
only  a  portion  of  the  food  being  ejected.  If  dilatation  of  the  stomach  with 
retention  of  the  contents  develops,  as  is  the  case  in  many  instances, the 
vomiting  may  be  of  a  characteristic  projectile  character  and  expel  at 
times  much  more  food  than  had  been  taken  at  the  last  feeding;  this 
showing  a  tendenc}^  for  food  to  accumulate  in  the  stomach.     The  empty- 


FiG.  242. — Stenosis  of  the  Pylorus. 
Boy  of  l}^  months,  in  the  Children's  Hospital  of  Philadelphia.     Illustration  shows  two 
peristaltic    waves.     General    condition    very    poor.     Rammstedt    operation,    but    death 
occurred  20  days  later. 


ing  of  the  organ  in  these  cases  may  occur  at  much  longer  intervals  and 
perhaps  only  once  or  twice  daily,  the  whole  of  the  food  taken  since  the 
last  vomiting  being  ejected  at  one  time.  The  loss  of  gastric  motor  power 
is  shown  by  the  evidences  of  dilatation  and  by  the  fincUng  with  the  stom- 
ach tube  or  by  examination  with  the  a;-ray  of  food  still  present  in  the 
stomach  from  4  to  10  hours  after  it  had  been  ingested.  The  food  vomited 
is  more  or  less  altered,  depending  upon  the  time  it  has  remained  in  the 
stomach,  and  there  is  often  an  admixture  of  mucus  and  sometimes  of 
streaks  of  blood.  Bile  is  rarely  regurgitated  and  there  is  no  evident 
nausea.  There  is  sometimes  an  increase  of  hydrochloric  acid  in  the 
vomited  matter,  in  other  cases  not. 

Constipation  is  a  very  characteristic  symptom.  There  may  be  no 
fecal  stool  for  some  clays  if  the  stenosis  is  complete,  what  is  passed  being 
not  feces,  but  merely  dark-brown  or  dark-green  mucus.  If  the  stenosis 
is  intermittent,  or  not  complete,  the  stools  may  be  fecal.  Loss  of  weight 
is  steady  and  rapid  in  most  cases  and  an  extremely  emaciated  state  may 


STENOSIS  OF  THE  PYLORUS  711 

be  reached  finally;  the  abdomen  being  sunken,  except  the  epigastrium 
which  is  distended.  Yet  to  this  there  are  occasional  exceptions  and  the 
weight  may  remain  almost  stationary  even  in  cases  where  there  is  no 
discoverable  evidence  that  any  food  reaches  the  intestine.  Peristaltic 
waves  in  the  stomach,  visible  through  the  thin  abdominal  vvalls,  consti- 
tute a  very  characteristic  symptom,  present  in  nearly  all  cases.  They 
are  seen  especially  after  food  has  been  taken,  or  just  before  vomiting 
is  about  to  take  place,  but  may  occur  at  any  time,  even  during  sleep,  or 
may  be  brought  into  evidence  by  stimulation  of  the  organ  through  friction 
of  the  abdominal  walls.  They  start  upon  the  left  side,  below  the  costal 
margin,  and  pass  toward  the  pylorus,  from  one  to  two  being  visible  at  a 
time  and  suggesting  the  presence  of  large  balls  rolling  under  the  abdomi- 
nal walls  (Fig.  242).  The  peristalsis  does  not  appear  to  be  productive 
of  pain.  Pain,  however,  sometimes  seems  to  follow  the  ingestion  of 
food,  and  an  infant  may  begin  to  take  nourishment  with  avidity,  but 
stop  with  a  cry  or  with  evidences  of  distress  after  a  few  mouthfuls. 
A  pyloric  tumor  may  be  felt  in  a  large  proportion  of  cases.  It  is  situated 
slightly  to  the  right  of  the  middle  line,  under  the  edge  of  the  liver,  or 
often  lower  near  the  vertebral  column  and  toward  the  umbihcus,  is  mova- 
ble, and  gives  the  sensation  of  a  small,  hard  body  of  the  size  of  a  small 
nut  or  an  enlarged  lymphatic  gland  about  1  to  1.5  inches  (2.54  to  3.8 
cm.)  in  length.  Slight  anesthesia  may  be  necessary  to  make  the  exami- 
nation satisfactorily.  The  urine  is  high-colored  and  scanty,  as  a  result 
of  the  inability  to  retain  and  absorb  liquids.  There  is  no  fever  unless 
from  a  complicating  digestive  or  other  disturbance. 

Course  and  Prognosis. — Concerning  the  probabihty  of  recovery  in 
stenosis  of  the  pylorus  there  is  much  difference  of  opinion.  The  chances 
are  greater  in  those  cases  in  which  the  development  of  symptoms  is 
delayed.  Undoubtedly  many  recover  when  spasm  is  the  chief  element. 
Heubner^  has  reported  19  recoveries  in  21  cases  treated  medically.  In 
such  cases  the  vomiting  may  gradually  diminish,  fecal  matter  appear 
in  the  stools,  and  the  excessive  peristalsis  of  the  stomach  finally  dis- 
appear. Patients  with  a  high  degree  of  hypertrophic  stenosis,  on 
the  other  hand,  grow  rapidly  worse,  the  symptoms  continuing  until 
the  infant  is  extremely  wasted,  and  death  finally  taking  place  after 
several  weeks  of  illness,  unless  timely  operation  has  been  performed. 
Even  after  operation  the  mortahty  has  been  high.  Ibrahim^  found  that 
in  the  172  reported  cases  of  operation  the  mortality  had  been  50.(5  per 
cent.  In  the  medically  treated  cases  it  was  36.5  per  cent.  The  total 
mortality  in  the  598  cases  of  both  kinds  of  stenosis  equalled  about  40 
per  cent.  Could  a  positive  differential  diagnosis  of  the  two  classes  of 
cases  be  made  promptly,  and  those  with  predominant  hyi)ertrophy  be 
operated  on  at  once,  the  mortality  figures  would  undoubtedly  be  nuich 
reduced,  since,  if  operation  is  to  be  done,  the  earlier  it  is  performed  the 
better  is  the  chance  for  the  patient.  A  more  prompt  decision,  earlier 
resort  to  operation,  and  improved  technic  have  of  recent  years  greatly 
increased  the  percentage  of  recoveries;  as,  for  instance,  in  Kichter's^ 
experience  of  but  13.6  per  cent,  mortality  after  operation,  and  Strauss'* 
of  but  4.6  per  cent.  All  statistic  are,  however,  to  a  certain  degree  mis- 
leading.    It  is  not  the  relative  mortality  of  medical  and  surgical  treat- 

'  ThcrajD.  d.  Gegenwart,  1900,  N.  S.,  VIII,  433. 
-  Loc.  cil. 

'  .Journ.  .\iner.  Med.  Assoc,  1914,  LXII.  353. 
'  Journ.  Amer.  Med.  Assoc,  1918,  LXXl,  807. 


712  THE  DISEASES  OF  CHILDREN 

ment  which  is  the  important  matter,  but  the  question  of  the  sort  of 
treatment  required  for  the  individual  case. 

Diagnosis. — ]\Iistakes  are  easily  made  because  the  symptoms  are 
not  always  typical  and  because,  too,  the  possibility  of  the  existence  of 
stenosis  does  not  occur  to  the  physician's  mind.  The  chief  characteristic 
symptoms  are  the  early  development;  the  obstinate  forcible  expulsive 
vomiting  without  sufficient  cause  in  the  way  of  digestive  disturbance;  the 
characteristic  peristalsis;  constipation;  and,  if  discovered,  the  pyloric 
tumor.  Congenital  conditions  such  as  atresia  of  the  pylorus  or  stricture 
of  the  duodenum  may  give  rise  to  mistakes,  but  both  of  these  malforma- 
tions are  extremely  uncommon;  and  the  latter  exhibits  biliary  vomiting 
while  the  former  is  the  cause  of  death  in  a  very  few  days.  A  mistaken 
diagnosis  may  also  arise  in  other  ways.  Thus,  for  instance,  the  stenosis 
can  occur  from  without,  as  by  pressure  of  the  cecum,  as  in  a  case  de- 
scribed by  Toporski.^  In  another  instance  (Gittings)^  an  appearance  of 
what  seemed  to  be  gastric  peristalsis  was  in  reality  produced  by  two  folds 
of  the  colon  overlying  the  stomach ;  and  Hoffa^  has  reported  a  number  of 
cases  in  which  gastric  peristalsis  was  present  without  the  slightest  rea- 
son to  suspect  stenosis.  In  stenosis  of  the  esophagus  the  food  is  regur- 
gitated entirely  unchanged,  almost  immediately  after  attempts  at  swal- 
lowing are  made;  and  even  if  dilatation  of  the  esophagus  is  present  and 
vomiting  is  somewhat  delayed,  there  is  no  evidence  of  gastric  digestion 
in  the  ejected  matter.  There  is  also  no  discoverable  gastric  peristalsis 
or  pyloric  tumor.  Valuable  for  diagnostic  purposes  is  the  employment 
of  the  Rontgen  ray  after  the  administration  of  bismuth.  This  will  show 
a  great  retardation,  or  even  entire  failure  of  passage  of  the  bismuth 
from  the  stomach  into  the  duodenum.  It  is  not,  however,  conclusive, 
as  I  have  seen  the  retardation  combined  with  projectile  vomiting  occur 
in  a  case  proven  by  autopsy  to  be  chronic  gastritis.  It  is  also  usually 
unnecessary  inasmuch  as  delay  in  the  emptying  of  the  stomach  can  be 
determined  equally  well  with  the  stomach-tube. 

The  distinction  between  the  two  classes  of  cases  is  usually  not  pos- 
sible with  certainty,  since  the  two  conditions  are  probably  always  associ- 
ated, although  in  varying  degrees.  In  the  cases  in  which  pylorospasm 
predominates  vomiting  often  begins  later  and  is  more  irregular  and  with 
longer  intervals;  the  obstruction  is  not  so  complete,  as  shown  by 
the  character  of  the  stools;  the  wasting  is  not  so  rapid;  and  dys- 
peptic disturbances  are  more  liable  to  be  present,  and  nervous  symp- 
toms may  exist.  In  cases  where  hypertrophic  stenosis  is  the  principal 
factor,  the  reverse  of  all  this  is  true  and  the  symptoms  appear  earlier 
and  are  in  every  way  worse.  Yet,  on  the  other  hand,  all  the  milder  symp- 
toms with  the  presence  of  fecal  stools  may  exist  in  cases  in  which  autopsy 
shows  that  decided  hypertrophy  had  been  present.  It  is  to  be  borne  in 
mind  that  hypertrophic  stenosis  may  exist  and  remain  latent  indefinitely; 
may^jbe  recognized  only  at  autopsy;  or  may  show  symptoms  only  after 
years.  It  is  possible,  too,  for  what  appears  to  be  simple  spasm  of  the 
pylorus  to  show  itself  for  the  first  time  in  childhood,  and  not  in  infancy. 
A  case  of  this  nature  was  reported  b}*  Graham.* 

Treatment.^ — Inasmuch  as  the  diagnosis  from  an  ordinary  digestive 
disturbance  is  not  at  first  possible,  the  earliest  treatment  must  be  purely 

1  Jahrb.  f.  Kinderheilk.,  1910,  LXXII,  285. 

2  Arch,  of  Pediat.,  1911,  XXVIII,  661. 

3  Monatsschr.  f.  Ivinderheilk.,  Grig.,  1912,  X,  523. 
*  Amer.  Journ.  Dis.  Child.,  1911,  II,  407. 


STENOSIS  OF  THE  PYLORUS  7]  3 

symptomatic.  Even  if  it  be  recognized  that  stenosis  is  present  the  same 
holds  true,  and  a  thorough  trial  of  medical  treatment  should  be  instituted. 
Efforts  must  be  made  to  relieve  the  vomiting  as  far  as  this  is  possible. 
Lavage  of  the  stomach,  practised  once  or  twice  daily,  is  the  best  means  for 
this  purpose,  using  a  warm  normal  salt  solution,  or  a  1  per  cent,  solution 
of  bicarbonate  of  soda.  If  much  exhaustion  follows  the  procedure  must 
be  abandoned.  Small  rectal  enemata  of  normal  salt  solution  should  be 
given  several  times  daily  to  supply  the  hquid  needed  by  the  system. 
Warm  baths  serve  the  same  purpose  to  a  certain  extent  and  tend  to 
favor  relaxation  of  the  spasm,  and  hot,  wet  applications  to  the  gastric 
region  are  useful  in  the  same  way.  Dietetic  treatment  is  very  important. 
Breast-milk  should  be  obtained  when  possible  in  cases  of  artificially  fed 
children  who  have  shown  any  symptoms  of  digestive  disturbance. 
If  this  is  not  feasible,  the  fat  of  the  diet  should  be  reduced  decidedly. 
If  the  child  is  already  nursing,  it  should  not  be  weaned,  but  the  milk  may 
be  given  diluted  or  in  smaller  quantity  and  at  longer  intervals.  In  some 
instances  albumen  water  or  whey  made  from  skimmed  milk  answers  well ; 
if  not,  other  food  must  be  experimented  with.  Very  httle  food  of  any 
sort  should  be  given  at  any  one  time,  and  the  intervals  may  be  long  or 
short  according  to  the  results  which  trial  shows  to  be  the  best.  Immedi- 
ately after  lavage  is  a  suitable  time  for  one  of  the  feedings.  In  some  cases 
feeding  by  gavage  has  answered  better  than  any  other  method.  Food 
given  by  the  bowel  is  usually  of  little  value,  but  albumen  water  or  other 
nourishment  may  be  tried  in  this  way. 

Treatment  by  drugs  is  generally  of  little  avail,  but  the  opiates, 
bromides  or  belladonna  may  be  tried  in  the  hope  of  relieving  spasm 
and  lessening  the  gastric  irritability.  Belladonna  certainly  seems  of 
value  in  some  cases. 

After  a  fair  trial  without  avail  of  the  methods  mentioned,  the  ques- 
tion of  operative  interference  arises.  This  is  a  serious  problem.  It  is 
important  not  to  resort  to  it  too  soon,  but  it  is  equall}^  important  not 
to  delay  it  so  long  that  the  infant  has  grown  too  weak  to  tolerate  any 
surgical  intervention.  It  is  a  radical  mistake,  in  my  opinion,  to  regard 
every  case  of  stenosis  as  a  subject  for  operative  interference;  but  con- 
tinued experience  with  this  disease  has  convinced  me,  on  the  other  hand, 
that  the  most  common  therapeutic  error  is  a  too  prolonged  delay  before 
operation  is  resorted  to.  I  have  had  cause  for  self-reproach  for  undue  delaj' 
in  advising  operation,  but  have  not  yet  regretted  recommending  an  early 
operative  interference.  Each  case  must  be  a  rule  for  itself,  and  the  gen- 
eral condition  of  the  infant,  and  the  gain  or  loss  of  weight  under  observa- 
tion must  be  the  guide  as  to  the  length  of  time  which  may  be  allotted  for 
medical  treatment;  but  after  a  careful  and  thorough  trial  of  this  for  not 
more  than  1  or  2  weeks  at  the  outside,  without  change  in  the  general  con- 
dition, nothing  is  to  l)e  gained  and  much  lost  by  persisting  with  it.  Should 
the  infant  l)e  in  bad  condition  when  first  seen,  or  improvement  does 
not  take  place  promptly,  the  time  mentioned  is  too  long,  anil  the  o|>era- 
tion  should  be  proceeded  with  immediately  or  periiaps  after  a  day's 
abstinence  from  food,  together  with  the  vigorous  eini^loyment  of  entero- 
clysis  and  hypodermoclysis.  Several  operations  have  been  proposed, 
that  of  gastroenterostomy  appearing  to  have  a  better  mortality  record 
than  either  divulsion  or  pyloroplasty.  INIore  recently  the  Rammstedt^ 
operation  of  simple  splitting  of  the  hypcrtrophied  mucous  membrane 
has  given  such  fav()rai)le  results  that  it  is  now  the  one  most  commonly 

1  iMcd.  Klinik.,  1912,  VllI,  1702. 


714  THE  DISEASES  OF  CHILDREN 

employed.  It  possesses  the  great  advantage  that  a  skillful  operator 
requires  not  more  than  20  minutes  for  its  completion.  A  somewhat 
similar  operation  has  been  devised  by  A.  Strauss^  in  which  the  mus- 
cular layer  is  spht,  and  then  again  divided  to  form  flaps  over  the  ex- 
posed mucous  membrane.  Strauss  reports  but  3  deaths  out  of  65  cases. 
After  operation  feeding  may  be  commenced  almost  immediately.  Breast- 
milk  should  be  used  if  possible,  but  only  very  small  amounts  given  at 
first,  and  the  full  quantity  permitted  only  by  a  week  or  more  after  the 
operation.  A  half-ounce  (15)  or  less  every  2  hours  may  be  given  at  first, 
and  this  increased  in  the  course  of  2  or  3  days  to  1  oz.  (30)  every  3  hours. 
Sometimes  it  is  better  at  the  beginning  to  dilute  with  one-quarter  water 
or  lime  water.  The  breast-milk  should  at  first  be  given  from  a  bottle. 
When  convalescence  is  well  under  way,  in  about  a  week,  nursing  directly 
from  the  breast  may  be  resumed.  If  this  is  found  not  to  agree  well, 
administration  of  the  food  from  the  bottle  should  be  promptly  recom- 
menced. Vomiting  is  hable  to  occur  during  the  first  few  days,  but  the 
keeping  the  infant's  head  somewhat  elevated  tends  to  check  this.  In 
many  cases  the  employment  of  hypodermoclysis  once  or  twice  a  day  is 
of  great  service  when  a  sufficient  amount  of  liquid  cannot  be  taken  or 
retained, 

CARDIOSPASM 

This  condition  occurring  in  infancy  is  analogous  to  the  pylorospasm 
of  that  period  of  life.  With  propriety  it  might  be  described  as  a  form 
of  spasm  of  the  esophagus.  Attention  has  been  called  to  it  by  Freund,^ 
Goppert,^  Beck*  and  others.  The  disease  is  probably  more  frequent 
than  ordinarily  supposed.  It  is  one  of  the  possible  causes  of  uncontrol- 
lable vomiting  in  early  childhood  or  infancy.  The  pathogenesis  of 
cardiospasm  is  not  well  understood.  The  principal  symptom  is  the  prompt 
vomiting  after  the  first  swallowing  of  food.  This  act  is  attended  by  very 
characteristic  actions,  viz.  regurgitation  and  repeated  reswallo wings; 
distinguished,  however,  from  rumination  in  that  there  is  no  difficulty  at 
all  attending  deglutition  in  the  latter  disease.  The  passage  of  a  sound 
encounters  obstruction  at  the  cardiac  orifice  of  the  stomach.  The  en- 
trance of  food  through  a  small  catheter  passed  directly  into  the  stomach  is 
not  followed  by  vomiting.  In  the  few  cases  as  yet  reported  the  prognosis 
appears  good.  In  the  line  of  treatment  a  sound  may  be  passed  system- 
atically, or  the  stomach  may  be  allowed  to  rest  entirely  for  a  few  days 
while  rectal  alimentation  is  employed. 

DILATATION  OF  THE  STOMACH 

A  moderate  dilatation  of  the  stomach  is  of  common  occurrence 
especially  in  infants.  A  degree  of  it  which  is  of  sufficient  importance  to 
produce    symptoms    and    demand    special   treatment   is    not   frequent. 

Etiology. — Dilatation  of  a  chronic  nature  may  follow  a  mechanical 
obstruction  such  as  stenosis  of  the  pylorus,  but  the  most  frequent  cause 
is;a  loss  of  tone  of  the  muscular  walls  dependent  upon  constitutional  con- 
ditions, notably  rickets  and  infantile  atrophy,  combined  with  constant 
overfeeding  especially  with  artificial  food,  resulting  in  indigestion,  de- 
composition and  formation  of  gas,  and  the  accumulation  of  this  and  dis- 

1  Loc.  cit. 

2  Monatsschr.  f.  Kinderh.,  1903,  II,  15. 

3  Therap.  Monatsschr.,  1908,  XXII,  390. 

*  Monatsschr.  f.  Kinderh.,  Grig.,  1911,  IX,  555. 


DILATATION  OF  THE  STOMACH  715 

tention  of  the  stomach.  There  may  be  observed  an  acute  dilatation  of  the 
stomach,  and  of  the  intestine  as  well,  occurring  sometimes  in  the  course 
of  respiratory  disease  or  after  abdominal  operations;  and  very  rarely 
a  sudden  and  even  fatal  acute  dilatation  may  develop  in  infants  "without 
any  discoverable  cause.  The  disease  in  this  form  has  been  reviewed  by 
Lucas.  ^ 

Pathological  Anatomy. — The  earHest  changes  are  simple  relaxa- 
tion of  the  gastric  walls,  but  this  is  followed  in  the  chronic  cases  by 
atrophy  of  all  the  layers.  The  shape  of  the  stomach  becomes  much 
altered,  the  lesser  curvature  changing  little  while  the  greater  extends 
downward  much  farther  than  normal,  the  dilatation  being  most  marked 
near  the  cardia.  This  produces  a  large  pouch,  and  the  normal  shape  and 
position  are  thus  entirely  altered.  The  gastric  capacity  is  increased 
many  times  above  that  normal  for  the  age.  With  the  dilatation  there 
may  be  combined  a  gastroptosis,  and  there  is  generally  an  accompanying 
dilatation  of  the  intestine. 

Symptoms. — These  are  principally  those  of  chronic  gastric  indi- 
gestion. (See  p.  723.)  There  is  often  vomiting  after  meals  or  at  irregular 
times,  eructation  of  gas,  and  abdominal  discomfort.  The  vomiting  is 
generally  not  frequent,  and  the  amount  ejected  is  surprisingly  large. 
The  appetite  is  sometimes  lost,  sometimes  abnormally  great.  The 
general  health  steadily  fails  and  the  child  becomes  anemic  and  emaciated. 
Constipation  may  alternate  with  diarrhea.  On  physical  examination 
the  gastric  region  is  found  distended  and  tympanitic,  and  sometimes  the 
stomach  can  be  clearly  outlined  by  percussion.  A  succussion-sound  may 
be  elicited  in  some  instances. 

Prognosis. — The  outlook  is  unfavorable  when  the  disease  is  due  to 
pyloric  stenosis.  When  dependent  upon  other  causes  the  prognosis 
is  usually  good,  if  dilatation  is  not  excessive,  although  recovery  may  be 
tedious.  If  due  to  indigestion  and  overfeeding,  recovery  should  follow 
without  difficulty;  when  rickets  is  the  predisposing  factor  a  cure  will  not 
be  obtained  until  the  constitutional  trouble  is  removed.  The  develop- 
ment of  gastric  dilatation  may  constitute  a  dangerous  comphcation  of 
other  diseases,  especially  pneumonia. 

Diagnosis. — ^It  is  verj^  easy  to  mistake  a  distended  colon  for  a 
distended  stomach,  and  when  both  viscera  are  dilated  distinction  by  simple 
percussion  is  almost  impossible.  To  determine  the  matter  the  stomach 
may  be  filled  with  water  a  few  hours  after  a  meal  and  the  lower  limit  of 
percussion  dullness  now  sought  for.  If  this  nearl.y  reaches  the  trans- 
verse umbihcal  line  the  organ  is  dilated.  The  administration  of  bismuth 
followed  by  examination  with  the  Rontgen  ray  may  likewise  be  used  to 
outUne  the  lower  gastric  border. 

Treatment. — Correction  of  the  diet  is  essential.  The  food  should  be 
nutritious  and  unirritating;  suitable  to  the  age  and  the  digestive  power 
of  the  patient.  It  nmst  be  given  frequently  and  only  in  small  quantities, 
the  amount  of  fluid  especially  being  reduced  in  older  children.  When 
the  appetite  is  inordinate,  not  sufficient  food  should  be  allowed  to  satisfy 
it.  As  the  stomach  grows  smaller  the  excessive  hunger  will  disappear. 
In  general  those  articles  of  diet  are  to  be  avoided  which  tend  to  produce 
an  accumulation  of  gas  in  the  stomach.  Systematic  lavage  daily  is  of 
value  in  cases  where  dilatation  is  decided.  Every  care  must  be  taken  to 
improve  the  general  health  by  tonic  and  hygienic  measures.  Massage 
is  of  service  and  the  administration  of  strychnine  is  of  value.  In  cases 
I  Arch,  of  Pediat.,  1909,  XXVI,  454. 


716  THE  DISEASES  OF  CHILDREN 

of  acute  dilatation  the  stomach-tube  should  be  passed  at  once  and  a 
hypodermic  injection  of  eserine  given. 

GASTRIC  HEMORRHAGE 

Etiology. — This  is  a  symptom  produced  by  a  variety  of  causes. 
It  has  already  been  referred  to  under  Melena  neonatorum  (p.  266). 
It  is  also  one  of  the  manifestations  of  a  more  general  tendency  to  hemor- 
rhage seen  in  the  hemorrhagic  disease  of  the  new  born  already  described 
(p.  264),  and  may  occur  in  scurvy  and  in  some  forms  of  purpura.  Apart 
from  the  ulcers  occasionally  found  in  melena,  gastric  hemorrhage  may 
result  at  a  later  period  from  ulceration  of  the  stomach  or  duodenum, 
or  from  injury  by  a  foreign  body. 

Symptoms. — These  consist  solely  in  the  vomiting  of  blood  which, 
on  investigation,  is  shown  to  have  its  origin  in  the  stomach.  Hemorrhage 
supposed  at  first  to  arise  in  the  stomach  may  come  from  the  nose,  mouth, 
or  lungs,  the  blood  having  been  swallowed  and  then  vomited.  Blood 
from  the  lungs  is  bright-red  in  color,  coughed  up,  and  frothy  if  it  is  expec- 
torated directly  without  previous  swallowing.  If  the  hemorrhage  from 
the  stomach  is  free,  the  blood  may  be  bright-red;  if  it  has  taken  place 
slowly  or  if  it  has  been  lying  for  some  time  in  the  stomach  it  is  dark- 
brown  or  black  in  color.  The  prognosis  is  usually  serious,  since  the  cause 
is  generally  a  severe  one. 

Treatment.- — This  depends  to  a  certain  extent  upon  the  cause, 
but  is  in  general  symptomatic.  The  patient  should  be  at  absolute  rest, 
an  ice-bag  placed  over  the  stomach  and  small  pieces  of  ice  swallowed.  No 
food  at  all  should  be  given.  An  opiate  hypodermically  is  of  benefit 
to  check  gastric  peristalsis.  Stimulants  may  be  required  by  way  of  the 
skin  or  the  rectum.  In  the  line  of  medicinal  treatment  suprarenal  ex- 
tract in  large  doses  is  the  best  remedy.  Gelatine  internally  is  sometimes 
of  service  also. 

GASTRIC  ULCER 

Etiology  and  Pathological  Anatomy. — This  is  an  unusual  con- 
dition in  early  life.  StowelU  collected  35  pubhshed  cases,  including  1 
of  his  own;  10  of  these,  however,  being  in  subjects  over  12  years  of  age. 
Jacobi^  added  a  number  of  others  to  the  list,  and  Lockwood^  has  collected 
about  125  cases,  including  a  number  of  unpubhshed  instances.  Several 
causes  may  produce  it  in  early  life.  It  is  oftenest  seen  in  melena,  al- 
though hemorrhage  from  the  stomach  from  this  disease  may  occur 
without  ulceration  discoverable  at  autopsy.  Sepsis  in  the  new  born  is 
likewise  a  cause;  acute  gastritis,  especially  that  from  corrosive  poison- 
ing occasionally  produces  it;  it  may  exceptionally  be  found  in  chronic 
gastritis,  and  in  rare  instances  tuberculous  ulceration  of  the  stomach 
is  found. 

The  primary  round  peptic  ulcer  of  the  stomach  is  rare.  It  is  only 
toward  the  end  of  later  childhood  approaching  puberty  that  it  begins  to 
be  comparatively  more  frequent.  It  is  more  common  in  girls  than  in 
boys.  The  peptic  ulcer  is  usually  single,  and  has  the  pathological  char- 
acteristics of  the  lesion  as  seen  in  adult  life  with  its  tendency  to  perfora- 
tion. This  is  in  contradistinction  to  gastric  ulcers  from  other  causes 
mentioned,  which  are  more  often  multiple  and  sometimes  very  numerous, 

1  Med.  Rec,  1905,  LXVIII,  52. 

2  New  York  Med.  Journ.,  1909,  XC,  837. 

3  Surgery,  Gynec,  and  Obstet.,  1914,  XIX,  462. 


FOREIGN  BODIES  IN  THE  STOMACH  717 

and  frequent!}'  have  the  characteristics  of  erosion  merely  or  of  folhcular 
ulceration. 

Symptoms.- — These  are  very  often  not  typical,  simulating  those  of 
acute  gastritis,  which  indeed  may  have  ulceration  accompanying  it;  and 
it  may  be  that  the  lesion  is  discovered  only  at  autopsy.  Sometimes  the 
perforation  of  an  ulcer  and  subsequent  peritonitis  is  the  first  indication 
that  any  serious  trouble  has  existed.  In  other  less  frequent  cases  there 
are  the  characteristic  s^'^mptoms  of  vomiting  of  blood  and  the  passage  of 
reddish  or  black  stools,  with  pain  and  tenderness  in  the  gastric  region. 
The  pain  is  sometimes  referred  to  other  parts  of  the  abdomen  and  the 
existence  of  appendicitis  may  be  suspected.  The  prognosis  is  serious  in 
all  forms  of  ulcer  in  which  the  symptoms  are  sufficient  to  render  a  diag- 
nosis even  provisional. 

Treatment. — The  measures  to  be  employed  consist  in  the  applica- 
tion of  cold  to  the  region  of  the  stomach;  absolute  rest  in  bed;  nourish- 
ment by  nutrient  enemata ;  and  abstinence  from  all  food  and  drink  by  the 
mouth,  except  that  older  children  may  swallow  small  pieces  of  ice.  Mor- 
phine may  be  given  hypodermically,  and  if  the  hemorrhage  is  severe 
suprarenal  extract  may  be  administered  by  the  mouth  and  gelatine 
subcutaneously,  with  great  care  that  the  gelatine  solution  is  properly 
prepared  and  sterilized.  Later  bismuth  or  nitrate  of  silver  may  be  given 
by  the  mouth.  If  there  is  reason  to  believe  that  perforation  has  occurred, 
or  if  hemorrhage  is  uncontrollable,  operation  is  indicated. 

RUMINATION 
(Merycismus) 

Of  this  affection  not  many  instances  have  been  recorded  in  early  life, 
although  it  is  very  probably  more  common  than  this  would  indicate. 
It  appears  to  be  analogous  to  the  rumination  normally  occurring  in  some 
of  the  mammalia,  but  is  in  the]human  race  a  pathological  process.  The 
condition  in  infancy,  at  which  period  it  seems  more  frequent  than  in 
childhood,  has  been  studied  by  Aschenheim,MBriining- and  Schippers.^ 
The  latter  collected  12  published  cases,  including  2  of  his  own.  Grulee^ 
adds  2  to  the  hst,  besides  a  number  observed  by  himself. 

The  symptoms  consist  in  a  series  of  repeated  regurgitations  of  small 
amounts  of  the  food  taken,  occurring  some  time  after  its  ingestion.  Some 
of  this  is  promptly  swallowed  again,  some  may  be  lost  from  the  moutii. 
There  is  none  of  the  forcible  character  which  pertains  to  true  vomiting. 
The  nature  of  the  food  seems  to  be  a  matter  of  no  influence.  The  prog- 
nosis, according  to  Grulee,  is  grave,  fully  25  per  cent,  of  the  cases  ending 
fatally.  The  administration  of  the  bromides  appeared  to  be  of  service 
in  a  case  reported  by  Lust.^ 

FOREIGN  BODIES  IN  THE  STOMACH 

As  with  the  esophagus  (p.  695),  foreign  bodies  of  very  varied  kinds 
may  find  their  way  into  the  stomach  of  infants  or  young  children  and,  less 
frequently,  of  older  children.  From  tliis  organ  they  may  be  vomited, 
or  may  pass  into  the  intestine  and  be  voided.     The  symptoms  are  very 

1  Zoitschr.  f.  Kindcrlipilk.,  Grip;.,  \m:\,  VIII,  101. 

2  Aicli.  f.  Kiixk'rh.,  U)V.\,  LX,  IKi. 

•'  Ncdcrl.  Tydschr.  v.  (Ipnccsk.,  litl 4,  I,  7S.5. 
"  Ainer.  Jouni.  Dis.  Child..  1017.  XIV.  210. 
^  Monatssohr.  f.  Kindcrheilk.,  OiIk.,  1911-12,  X,  31t). 


718  THE  DISEASES  OP  CHILDREX 

indefinite.  There  may  be  an  attack  of  choking  at  the  time  of  swallowing. 
and  possibly  pain  in  the  throat,  or  shght  hemorrhage  if  the  object  is  not 
of  a  smooth  nature.  When  once  in  the  stomach  there  are  usually  no 
sjTaptoms  whatever,  unless  irritation  of  the  mucous  membrane  is  set 
up  by  an  object  of  a  sharp  or  rough  character.  While  in  the  ^-iscus  the 
body  may  be  the  cause  of  obstruction,  inflammation,  abscess,  or  perfo- 
ration. It  is  important  to  remember  in  the  matter  of  diagnosis  that 
parents  are  frequently  positive  that  a  foreign  body  has  been  swallowed 
by  the  child,  but  that  later  this  is  foimd  perhaps  upon  the  floor.  The 
emplojinent  of  the  Rontgen  ray  is.  cf  course,  necessaiy  to  estabhsh  the 
presence  of  the  body.  How  long  it  may  remain  in  the  stomach  without 
the  production  of  symptoms  and  without  danger  depends  much  upon  its 
shape  and  character.  I  recall  an  instance  where  the  radiogianis  showed 
a  metal  whistle  from  a  rubber  toy  remaining  for  9  days  in  the  stomach 
before  it  entered  the  pylorus. 

Regarding  treatment,  the  removal  of  the  foreign  body  is  necessar^^, 
but  there  need  be  no  undue  hurr^-  to  resort  to  such  a  serious  operation  as 
gastrostomy  so  long  as  there  are  no  sj-mptoms  present,  and  a  smooth 
body  of  moderate  size  is  shown  by  the  fluoroscope  to  be  changing  its 
position  from  time  to  time  in  the  stomach:  i.e.  is  not  imbedding  itself  in 
the  mucous  membrane.  The  chance  of  passage  through  the  pylorus  is 
to  be  estimated  by  comparing  the  known  size  of  the  foreign  body  with 
that  of  the  pylorus  at  certain  ages.  According  to  Hess^  the  diameter  of 
the  pylorus  in  the  new  born  is  4.2  mm.  (0.17  in.) :  at  2  to  3  months  6  mm. 
(0.24  in.) ;  and  at  6  months  7  mm.  (0.28  in.) :  while  Pfaundler-  gives  the 
circumference  in  the  new  born  as  2  cm.  (0.78  in.):  and  at  8  years  4  cm. 
(1.57  in.).  Nevertheless  I  have  known  objects,  after  a  considerable  delay, 
safely  to  pass  a  pylorus  the  estimated  size  of  which  had  seemed  entirely  too 
small  to  permit  of  this.  Before  any  thought  of  operation  is  entenained, 
efforts  should  be  made  to  aid  the  exit  of  the  body  and  to  protect  the 
gastric  mucous  membrane.  This  is  best  accomplished  by  the  admini- 
stration of  food  which  will  coat  the  object,  such  as  potato,  bread,  and 
cereal  porridges.     No  purgative  or  emetic  should  be  given. 

A  form  of  foreign  body  sometimes  found  is  the  hair-ball.  This  has 
occurred  in  children  who  are  in  the  habit  of  chewing  haii"  from  the  head, 
fur.  wool  from  blankets,  cotton,  and  the  like.  Generally  the  amount 
swallowed  is  not  large  and  the  materiaLpasses  promptly  into  the  intestine 
and  is  voided:  but  in  some  cases  this  does  not  occur  and  the  .size  of  the 
hair-ball  is  gradually  increased  by  the  continuance  of  the  bad  habit, 
until  it  may  reach  such  dimensions  that  it  forms  a  tmnor  recognizable  by 
palpation  and  giving  a  soft,  crackhng  sensation  to  the  fingers.  The 
passage  of  the  stomach-tube  may  be  interfered  with  by  the  pre,senee  of 
the  mass.  Possibly  small  amounts  of  hair  are  from  time  to  time  evacuated 
in  the  stools.  The  SATnptoms  are  indefinite,  and  consist  at  the  most  of 
moderate  e^^dences  of  indigestion  or  of  gastric  distre.ss.  Operation  is 
necessary. 

MALFORMATIONS,  MALPOSITIONS  AND  NEOPLASMS  OF  THE 

STOMACH 

Malformations,  with  the  exception  of  pyloric  stenosis,  are  of  gjeat 
rarity.  Malpositions  are  occasionally  .seen.  The  stomach  may  occupj'^ 
the  right  side  of  the  abdomen  in  cases  of  transposition  of  the  viscera,  or 

1  Amer.  Joum.  Child.  Dis..  1914.  VII,  184. 
-  Bibliotheca  medica,  1898,  H.  .5.  .^5. 


ACUTE  GASTRIC  IXDIGESTIOX  719 

may  be  found  partially  within  the  thoracic  ca%-ity  in  diaphragmatic 
hernia.  Through  the  presence  of  adhesions  it  may  retain  the  more 
vertical  prenatal  position.  It  may  be  partially  di^'ided  into  two  portions 
by  a  constricting  wall:  may  remain  of  ver^-  small  size,  with  thickened 
walls:  or  may  exhibit  complete  closure  at  either  orifice. 

Morbid  growths,  too.  are  yery  uncommon  in  early  life.  Even  tuber- 
culosis of  the  stomach  is  rare.  Osier  and  McCrae^  collected  6  reported 
cases  of  cancer  imder  the  age  of  10  years.  Sarcoma  and  h-mphadenoma 
are  even  less  often  seen.  Other  cases  of  morbid  growths  have  since  been 
reported. 

ACUTE  GASTRIC  INDIGESTION 

Although  pathologically  this  is  to  be  distinguished  from  acute  gas- 
tritis, being  merely  a  functional  disturbance,  the  sA-mptoms.  especially 
at  the  beginning,  are  very  similar,  and  a  diagnosis  cannot  always  be 
made.  The  two  diseases  are.  however,  different  and  should  be  considered 
separately.  A  distinction  is  also  to  be  drawn  between  gastric  indigestion 
in  infants  and  that  in  older  children. 

EtioIog\ . — The  cause  in  infants,  whether  breast-fed  or  artificially 
fed.  is  the  ingestion  of  imsuitable  or  of  too  large  a  quantity  of  milk. 
Sometimes  the  condition  of  the  mother,  as.  for  instance,  after  emotional 
excitement,  produces  milk  which  causes  acute  indigestion  in  the  child. 
The  gi\'ing  the  infant  other  articles  of  food  to  which  it  is  unaccustomed 
may  produce  the  same  result.  In  older  children  overfeeding,  or  the 
eating  of  distinctly  inchgestible  substances,  such  as  cake,  candy,  pastry, 
imripe  fruit .  or  even  ripe  fruit  of  certain  sorts,  and  the  like,  has  the  same 
effect.  Nervous  influences  are  also  a  powerful  factor,  and  acute  indiges- 
tion may  follow  the  fatigue  from  overexercise,  excitement  of  any  sort, 
and  unusually  ho:  weather. 

Pathological  Anatom> . — Probably  no  organic  lesions  exist,  the 
distiu-bance  being  purely  a  functional  one.  The  proper  secretion  of  the 
stomach  is  interfered  with  and  the  motor  power  temporarily  unpaired. 

Symptoms. — As  a  result  of  the  disturbance  of  the  gastric  function 
the  food  Ues  too  long  in  the  stomach  and  imdergoes  abnormal  changes. 
The  first  sxTuptom  is  nausea,  complained  of  by  older  children,  and  in 
infants  shown  by  pallor  of  the  whole  face  or  of  the  region  about  the  mouth 
and  by  perspiration  of  the  forehead.  Pain  also  may  be  present.  Vomit- 
ing then  occurs  and  the  child  is  temporarily  relieved.  The  vomited 
matter  shows  a  distinctly  abnormal  quahty.  In  infancy  it  is  always 
sour  and  there  are  often  large,  curdy  masses  ejected.  In  older  children 
it  is  also  sour  and  various  articles  of  food  are  found,  showing  little  e\'i- 
dence  of  any  digestive  process  ha\nng  taken  place  even  5  or  more  hours 
after  eating.  A  single  act  of  vomiting  may  be  sufficient  to  empty  the 
stomach,  but  more  often  it  is  repeated  after  an  interval:  this  occurring 
jjerhaps  several  times.  Meanwhile  there  is  often  more  or  less  fever, 
coating  of  the  tongue,  offensive  breath,  thirst,  prostration,  epigastric  dis- 
tress and  pain,  perhaps  headache,  constipation,  and  very  frequently 
eventually  diarrhea.  The  urine  is  scanty  and  high  colored:  the  patient 
may  be  somnolent  or  very  restless,  or  even  eonx'ulsions  may  occur.  In 
exceptional  cases  coma  may  follow.  In  the  intervals  between  the  attacks 
of  vomiting  there  may  be  a  desire  for  food,  or  entire  loss  of  appetite  may 
continue. 

'  New  York  Med.  Joum.,  1900,  LXXI,  5S1. 


720  THE  DISEASES  OF  CHILDREN 

Course  and  Prognosis.^ — If  properly  treated,  and  especially  if 
no  food  is  given,  the  acute  sjanptoms  are  usually  over  in  from  6  to  12 
hours  and  all  evidences  of  the  disease  in  from  2  to  3  days.  The  prognosis 
is  nearly  always  good,  even  though  the  symptoms  may  for  a  time  seem 
alarming.  Death,  however,  may  take  place  especially  in  weakly  subjects 
in  early  infancy,  or  the  disease  may  be  followed  by  more  serious  digestive 
disturbances. 

Diagnosis. — This  is  easy  only  when  the  whole  history  can  be  ob- 
tained and  the  nature  of  the  cause  discovered.  To  distinguish  between 
acute  gastric  indigestion  and  acute  gastritis  is  usually  impossible  at  the 
outset  and  even  sometimes  later,  except  at  autopsy.  Indigestion  is 
usually  of  shorter  duration  and  less  severe.  It  is  also  more  frequently 
encountered.  Should  the  severe  symptoms  persist  and  vomiting  con- 
tinue after  the  stomach  should  have  been  quite  emptied;  and,  especially 
if  the  vomited  matter  contain  blood-streaked  mucus,  there  is  reason  to 
believe  that  gastritis  is  present.  The  sudden  commencement  with 
vomiting  and  sometimes  convulsions  may  suggest  the  onset  of  pneumonia, 
influenza,  meningitis,  or  some  other  acute  febrile  disease;  and  even  later 
in  the  attack  the  presence  of  the  nervous  or  meningeal  symptoms  not 
infrequently  attending  acute  indigestion  may  make  the  diagnosis  for  a 
time  uncertain. 

Treatment.- — The  first  indication  is  to  empty  the  stomach  and 
bowels  by  abstinence  from  food  and  the  giving  of  a  purgative.  For  the 
latter  purpose  castor  oil  is  excellent  in  infancy  unless  nausea  and  vomiting 
be  so  active  that  there  is  reason  to  fear  the  drug  may  not  be  retained. 
Calomel  in  doses  of  3^^ o  grain  (0.006)  every  half  hour  until  1  grain 
(0.07)  or  less  is  taken  is  often  of  service.  No  food  whatever  should  be 
given,  but  there  is  no  objection  to  water  at  the  beginning,  since,  if  vom- 
ited, it  thus  produces  practically  a  washing-out  of  the  stomach.  Lavage 
with  the  stomach-tube  is  very  effective  but  usually  not  needed,  and  the 
same  is  true  of  emetics.  If  vomiting  is  troublesome  small,  repeated  doses 
of  bismuth  subcarbonate  and  soda  bicarbonate  are  useful,  giving  5  grains 
(0.32)  of  the  former  and  2  (0.13)  of  the  latter  at  1  or  2  years  of  age.  A 
very  serviceable  remedy  consists  in  teaspoonful  doses  of  equal  parts  of 
lime  water  and  cinnamon  water  given  hourly  to  infants,  with  larger  doses 
for  older  children.  The  application  of  a  hot-water  bag  or  a  mustard 
plaster  to  the  epigastrium  is  often  useful.  The  return  to  food  should  be 
made  cautiously,  since  relapses  are  likely  to  occur.  In  the  case  of  arti- 
ficially fed  infants  albumen  water  or  barley  water  in  small  amounts, 
frequently  repeated,  is  an  excellent  first  food;  and,  after  a  considerable 
interval,  the  original  bottle-mixture  diluted  with  water  and  lime  water 
and  perhaps  with  the  fat  omitted.  In  the  case  of  breast-fed  infants  the 
supply  of  milk  should  be  maintained  by  systematic  pumping,  but  none 
given  for  at  least  24  hours  and  then  very  little  at  a  time.  In  older  children 
the  first  food  may  be  broth  free  from  fat,  albumen  water,  beef-juice,  and 
the  like;  and  later  skimmed  milk  and  lime  water.  The  greatest  success 
in  the  treatment  at  any  age  depends  upon  sufficient  thorough  starvation 
and  a  cautious  and  slow  return  to  the  usual  diet.  Where  there  is  a  tend- 
ency to  repeated  attacks  of  acute  gastric  indigestion  there  is  something 
radically  wrong  with  the  diet.  In  the  case  of  artificially  fed  infants  some 
modification  of  the  food  should  be  tried.  In  breast-fed  babies  the 
mother's  milk  should  be  analyzed,  and  the  effort  made  to  modify  this  as 
far  as  possible,  if  necessary,  by  proper  dietetic  and  hygienic  measures 
(see  p.  106),  or  to  change  the  amount  given  or  the  frequency  of  nursing. 


ACUTE  GASTRITIS  721 

ACUTE  GASTRITIS 

This  differs  from  acute  gastric  indigestion  in  the  presence  of  distinct 
organic  alterations.  It  is  of  very  much  less  frequent  occurrence  and, 
when  present,  is  usually  combined  with  lesions  of  other  parts  of  the  gastro- 
enteric tract.  Manj'  cases  supposed  to  be  gastritis  exhibit  at  autopsy 
none  of  its  lesions. 

Etiology. — Diverse  causes  may  be  at  work,  and  the  disease  can  be 
divided  accordingly  into:  (a)  the  acute  catarrhal,  (h)  the  corrosive,  and 
(c)  the  pseudomembranous  forms.  The  causes  in  the  catarrhal  variety  are 
much  the  same  as  in  acute  gastric  indigestion,  and  the  disease  is  more  com- 
mon in  infancy  than  later.  In  addition  to  the  disturbance  of  function 
there  is  inflammation  added,  probably  dependent  upon  an  infection.  In 
corrosive  gastritis  the  cause  is  the  introduction  of  an  irritant  poison 
as  in  the  case  of  corrosive  esophagitis.  Pseudomembranous  gastritis, 
although  much  oftener  seen  in  children  than  in  adults,  is  rare.  It  is 
usually  dependent  upon  the  germ  of  diphtheria,  less  frequently  on  some 
other  germ;  and  may  occur  in  small-pox,  scarlet  fever  and  other  infectious 
diseases,  or  in  sepsis  in  the  new  born. 

Pathological  Anatomy. — (a)  In  catarrhal  gastritis  the  mucous 
membrane  is  swollen  and  reddened  and  covered  with  an  abundant,  thick 
layer  of  mucus,  often  with  a  brownish  stain  from  sHght  hemorrhage.  The 
blood-vessels  are  injected  and  small  punctate  hemorrhages  are  visible. 
Microscopical  examination  shows  an  infiltration  of  the  mucosa  with 
round  cells,  and  sometimes  of  the  submucosa  to  a  limited  extent.  There 
may  be  localized  disintegration  of  the  superficial  epithelium  in  scattered 
patches,  or  rarely  even  the  production  of  erosions  (ulcerative  gastritis). 
Large  numbers  of  bacteria  are  present  in  the  gastric  contents,  which 
consist  of  mucus  and  undigested  food.  The  stomach  may  be  either 
dilated  or  smaller  than  normal. 

(b)  In  corrosive  gastritis,  when  death  has  occurred  promptly,  there 
are  found  only  the  evidences  of  destruction  of  the  gastric  walls,  varying  in 
degree  according  to  the  intensity  of  the  action,  and  without  signs  of  in- 
flammation. There  may  be  scattered  losses  of  substance  involving  the 
mucous  membrane  onty  or  extending  through  the  wall  of  the  stomach. 
If  the  destructive  action  has  been  less  intense  and  hfe  has  continued 
longer,  there  are  found  the  lesions  of  acute  gastritis  combined  with  scat- 
tered, shallow,  hemorrhagic  erosions  of  the  mucous  membrane  or  deeper 
ulcerations. 

(c)  Pseudomembranous  gastritis  exhibits  a  greyish-green  membrane 
on  a  part  or  all  of  the  fining  of  the  stomach,  consisting  of  desquamated 
epithelium,  bacteria,  granular  matter,  and  fibrin,  and  there  is  an  extensive 
round-celled  infiltration  of  the  mucosa  and  even  of  the  laj^ers  beneath.  It 
has  been  especiall}'  studied  bj'  Bednar,'  Orth-  and  Parrot.^ 

Symptoms,  ia)  Catarrhal  Gastritis.  -The  onset  in  infancy  is  with 
naus(>a,  voniiling,  tlurst,  gastric  pain,  high  fever,  loss  of  appetite,  coateil 
tongue,  constipation,  somnolence  or  restlessness,  and  jirostration.  The 
symptoms  at  first  cannot  be  distinguished  from  those  of  acute  gastric 
dyspepsia,  but  instead  of  disappearing  promptly,  efforts  at  vomiting 
continue  even  when  no  food  is  taken,  the  ejected  matter  containing 
mucus,  sometimes  blood-streaked.  Alxlominal  discomfort  or  pain 
persists,  the  tongue  remains  coated,  and  the  breath  is  heavy.     Fever 

'  Kraiikli.  d.  XcukoIjdiciioii,  ISIy'.i,  I,  '.Ml. 
■-L('liil)iicli  d.  spec.  ])atli(>l()K.  .Viiatoiiii*',  1S87,  I,  704. 
•^  Pron.  nu'd.,  1875,  111,  393. 
46 


722  THE  DISEASES  OF  CHILDREN 

lessens  in  degree,  but  continues  present,  with  great  thirst  and  loss  of 
appetite.  Constipation  usually  gives  place  to  diarrhea,  and  there  is 
more  complete  prostration  than  mere  indigestion  accounts  for.  In 
older  children  the  pain  and  vomiting  are  decided  features,  but  the  pros- 
tration and  fever  are  generally  less. 

(6)  Corrosive  Gastritis. — The  symptoms  are  verj-  acute  and  severe. 
There  is  the  accompanj^ing  evidence  of  inflammation  of  the  mouth, 
pharynx,  and  esophagus.  Vomiting  occurs  immediately,  the  vomited 
matter  being  blood-stained.  If  death  does  not  quickly  result,  there 
develop  the  symptoms  of^'acute  catarrhal  gastritis  in  a  very  severe  form, 
together  with  those  of  enteritis. 

An  analogous  condition  is  seen  in  the  hemorrhagic  erosions  {ulcerative 
gastritis)  sometimes  present  in  septic  conditions  in  the  new  born,  or  as  an 
attendant  upon  severe  cases  of  acute  catarrhal  gastritis,  thrush,  or  intes- 
tinal ulceration.  There  are  no  characteristic  symptoms  distinguishing 
this  from  acute  gastritis  except  a  greater  tendency  to  gastric  hemorrhage. 

(c)  Pseudomembranous  Gastritis. — This  condition  has  no  character- 
istics by  which  it  can  be  distinguished  during  life.  The  symptoms  may  be 
those  of  acute  catarrhal  gastritis  or  there  may  be  few  evidences  of  disorder 
of    the    stomach. 

Course  and  Prognosis. — The  symptoms  of  catarrhal  gastritis  are 
most  severe  at  the  beginning  of  the  attack.  Their  duration  is  a  few 
days  to  a  week,  but  they  are  hable  to  be  followed  by  intestinal  symp- 
toms. Recovery  usually  results.  Occasionally  in  infancy  an  initial 
convulsion  may  cause  death,  or  a  fatal  issue  may  take  place  from  pros- 
tration. Unless  properly  treated  there  is  great  danger,  too,  of  relapse,  or 
of  the  occurrence  of  repeated  attacks  with  a  final  development  of  a  chronic 
gastritis. 

In  corrosive  gastritis  the  prognosis  is  very  grave.  Collapse  is  liable  to 
result  very  promptly  and  death  to  follow  in  a  few  hours  after  the  ingestion 
of  the  poison;  or  life  may  be  prolonged  for  a  time,  but  death  occur  in  2  to  3 
days  from  prostration,  often  with  symptoms  of  a  very  severe,  acute 
gastritis.  Infants  nearly  always  die.  Older  children  may  survive  and 
later  show  evidences  of  chronic  gastritis  or  of  lesions  elsewhere  in  the 
gastroenteric  tract.  The  prognosis  of  ■pseudomembranous  gastritis  is 
very  unfavorable. 

Diagnosis.— The  recognition  of  mtarrhal  gastritis  is  attended  by 
many  difficulties.  The  milder  cases  cannot  be  differentiated  with  cer- 
tainty from  gastric  indigestion,  and  it  is  only  the  persistence  of  symptoms 
which  renders  the  diagnosis  justifiable.  The  subacute  cases  strongly 
suggest  typhoid  fever,  but  are  to  be  distinguished  in  most  instances  by 
the  more  irregular  fever,  which  has  a  tendency  to  diminish  after  the  onset 
instead  of  to  increase.  The  more  severe  cases  suggest  the  onset  of 
pneumonia,  meningitis,  or  scarlet  fever,  but  can  be  recognized  by  the 
failure  in  a  short  time  of  any  of  the  characteristic  symptoms  of  these  to 
develop.  Corrosive  gastritis  is  marked  by  the  extremely  sudden  and 
severe  onset,  collapse,  the  evidences  of  corrosion  about  the  mouth, 
and  the  history  of  the  ingestion  of  an  irritant  substance.  The  rare  cases 
of  erosion  from  other  causes  exhibit  no  distinguishing  symptoms  except 
a  greater  tendency  to  hemorrhage. 

Treatment. — The  treatment  of  catarrhal  gastritis  does  not  differ 
from  that  of  acute  gastric  indigestion.  No  food  should  be  given  at  first; 
small  pieces  of  ice  may  be  swallowed;  a  free  purgative  may  be  adminis- 
tered, if  vomiting  will  permit,  in  order  to  empty  the  stomach  and  bowels 


CHRONIC  GASTRITIS— CHRONIC  GASTRIC  INDIGESTION       723 

if  the  case  is  seen  earh'  or  if  the  giving  of  food  has  been  persisted  with. 
In  some  instances  lavage  is  of  great  benefit,  using  a  normal  salt-solution  or 
a  0.5  to  1  per  cent,  solution  of  bicarbonate  of  soda,  the  latter  being  selected 
if  the  vomited  matter  continues  very  acid.  Should  vomiting  be  very 
persistent  bismuth  may  be  administered  in  small  doses  frequently  re- 
peated, or  the  lime  water  and  cinnamon  water  combination  as  in  gastric 
indigestion.  The  return  to  food  should  be  even  more  cautiously  at- 
tempted than  in  the  milder  disease,  albumen  water  or  barley  water  being 
the  first  given,  or  fat-free  broth  in  the  case  of  older  children. 

The  treatment  of  corrosive  gastritis  consists  in  the  immediate  adminis- 
tration of  the  proper  antidote  if  the  case  is  seen  early  enough.  The 
stomach  should  also  be  thoroughly  washed  out,  but  very  carefully  with 
due  regard  to  the  softened  condition  of  this  organ  and  of  the  esophagus. 
After  this  follows  the  administration  of  ice;  ice- water;  cold  demulcent 
fluids,  such  as  albumen  water  and  solution  of  gum-arabic;  oils;  and  the 
like.  Prostration  is  to  be  overcome  by  cardiac  stimulants  hypodermic- 
ally  or  whiskey  given  b}^  the  rectum,  and  pain  and  repeated  vomiting  by 
the  hypodermic  use  of  morphine. 

CHRONIC  GASTRITIS— CHRONIC  GASTRIC  INDIGESTION 

Gastric  indigestion  frequently  repeated  or  long  continued  will  finally 
produce  distinct  lesions.  Consequently  every  case  of  chronic  indigestion 
may  be  regarded  as  based  upon  an  organic  as  well  as  a  functional  dis- 
turbance. Certainly  no  sharp  clinical  distinction  can  be  made  between 
the  functional  and  the  organic  disease.  It  is  equally  true  that  there  is 
usually  present  a  combination  or  even  a  predominance  of  intestinal 
disturbance  (gastroenteritis).  The  cases  in  which  this  predominance 
exists  are  discussed  elsewhere  (p.  738). 

Etiology. — This  disease,  more  common  in  infants  than  in  older 
children,  is  the  result  of  a  series  of  recurrences  of  acute  gastric  indigestion, 
or  of  a  single  severe  attack  of  this,  or  of  acute  gastritis  from  which  com- 
plete recovery  had  not  been  made ;  or  it  may  develop  without  any  previous 
acute  condition.  In  any  event  the  chronic  disorder  is  often  dependent 
upon  persistence  with  an  improper  diet.  This  is  especially  true  in  in- 
fancy, at  which  time  a  food  constantly  too  rich  in  some  ingredient,, 
especially  fat,  is  so  often  given,  or  a  diet  of  other  substances  than  milk 
employed  entirely  unsuitable  for  the  age.  The  existence  of  rickets, 
tuberculosis,  syphilis,  or  other  chronic  diseased  condition  affecting  the 
general  nutrition  likewise  predisposes  to  the  development  of  chronic 
gastritis. 

In  older  children  the  persistent  giving  of  food  of  an  improper  character 
is  probably  the  most  frequent  cause;  but  hurried  eating  with  imperfect 
mastication;  eating  at  irregular  times,  especially  between  meals;  antl 
imperfect  hygiene  of  any  sort,  including  lack  of  exercise  and  sleep,  over- 
fatigue, and  undue  stimulation  of  the  emotions  are  very  powerful 
factors.  Chronic  gastritis  may  follow  also  an  acute  infectious  disorder 
or  may  attend  a  chronic  debilitat'ng  disease.  There  occurs,  too,  an 
inheritance  of  a  predisposition  to  the  malady,  and  the  presence  of  a 
neurotic  temperament  is  often  an  important  factor. 

Pathological  Anatomy. — The  stomach  is  somewhat  dilated  and 
the  mucous  membrane  is  found  covered  with  a  tenacious  layer  of  nuicus, 
exhibits  prominent  ruga',  is  thickened,  anil  is  greyish  in  color;  or  may 
exhibit  hyperemia  in  spots  combined  with  punctiform  hemorrhages. 
Small  hemorrhagic  or  other  erosions  may  be  seen  in  severe  cases,  and  occa- 


724  THE  DISEASES  OF  CIIILDRES 

sionally  more  distinct  ulcerations  of  larger  size.  Microscopically  there  is 
a  round-celled  infiltration  of  the  mucosa,  slight  in  the  milder  cases,  with 
compression  and  partial  destruction  of  the  gastric  tubules.  Numerous 
bacteria  are  present  in  the  adherent  mucus.  The  blood-vessels  of  the 
mucous  and  subnmcous  layers  are  congested,  and  there  may  be  thickening 
of  the  entire  wall  of  the  stomach  in  severe,  long-continued  cases. 

Symptoms. — The  symptoms  in  infancy  are  often  somewhat  similar 
to  those  of  acute  gastric  indigestion,  although  less  severe;  but  not  in- 
frequently the  onset  is  insidious,  marked  by  loss  of  appetite;  coated 
tongue,  occasional  nausea  and  vomiting,  and  failure  of  health.  Even- 
tually the  vomiting  becomes  the  most  striking  symptom.  This  may  occur 
proniptly  after  each  taking  of  nourishment,  or  less  often  only  at  longer 
intervals,  the  food  then  being  vomited  in  small  amounts  and  this  repeated 
until  the  stomach  is  empty.  Often  the  vomited  matter  consists  only 
of  a  ver}^  acid,  watery  Uquid,  while  the  solid  portion  of  the  food  is  retained. 
In  long-continued  cases  in  which  the  condition  has  advanced  to  the  pro- 
duction of  actual  inflammation  the  vomiting  of  mucus  is  a  prominent 
feature.  This  is  less  marked  where  the  functional  disturbance  still 
predominates.  The  breath  has  an  offensive,  very  sour  odor  and  eructa- 
tion of  gas  of  the  same  character  is  very  common.  The  tongue  is  coated 
and  the  bowels  usually  constipated;  sometimes  diarrheal.  The  stomach 
is  often  greatly  distended  by  gas,  resulting  in  pain  and  tenderness,  rest- 
lessness, fretfulness,  disturbed  sleep,  and  difficulty  in  taking  food  even 
though  the  child  be  evidently  hungry.  The  appetite  may  be  very  large 
but  is  usually  nmch  diminished.  Physical  examination  shows  the  dis- 
tended tympanitic  gastric  region  and  even  sometimes  a  constant  gastric 
dilatation.  (See  p.  714.)  The  employment  of  the  stomach-tube  shows 
the  presence  of  food  hours  after  the  organ  ought  to  have  been  empty. 
(See  Digestion,  p.  44.)  The  contents  are  in  various  stages  of  abnor- 
mal decomposition,  with  mucus  and  many  bacteria.  This  condition 
of  the  gastric  contents  depends  upon  the  continued  disturbance  of  normal 
secretion  and  the  inhibition  of  the  gastric  motor  power,  permitting  ab- 
normal fermentation;  while  the  inflammation  of  the  mucous  membrane 
produces  the  abundant  mucus.  There  is  nearly  always  undue  acidity, 
chiefly  from  the  fermentative  changes,  the  hydrochloric  acid  being 
generally  below  normal  in  amount. 

The  symptoms  described  may  be  nearly  continuous,  or  may  vary  from 
time  to  time;  with  temporary  improvement  in  which  the  appetite  returns 
and  vomiting  is  much  less,  to  be  followed  by  recrudescences  with  evidences 
of  acute  gastritis.  Meantime  the  general  health  gradually  deteriorates; 
there  is  failure  to  gain  in  weight  or  even  loss  of  it,  and  anemia  is  present 
with  the  general  signs  of  extreme  malnutrition. 

In  older  children  there  is  coated  tongue,  heavy  breath,  pain  or  dis- 
comfort in  the  gastric  region,  and  distention  and  nausea  after  food. 
Vomiting,  although  a  common  symptom,  is  not  so  frequent  as  in  infancy. 
It  may  occur  after  every  meal;  or  only  in  the  early  morning  before  taking 
food ;  or  irregularly,  the  vomited  matter  being  the  fermented  food,  always 
with  a  large  amount  of  mucus.  There  is  also  frequent  eructation  of  gas 
and  perhaps  regurgitation  of  small  amounts  of  the  gastric  contents  be- 
tween the  attacks  of  vomiting.  Appetite  may  be  lost  or  abnormally 
great,  or  there  may  be  a  desire  for  only  some  articles  of  diet.  The 
breath  is  offensive,  and  constipation  is  the  rule.  The  so-called  "stomach 
cough"  mav  be  one  of  the  chief  symptoms.  Ciradually  a  certain  degree 
of  malnutrition  develops,  with  headache,  debility,  fretfulness,  disturbed 


CHRONIC  GASTRITIS—CHRONIC  GASTRIC   INDIGESTION        725 

sleep,  anemia,  emaciation,  malaise  and  a  large  array  of  nervous  or  other 
indefinite  symptoms.  In  many  eases  these  constitutional  manifestations 
are  much  more  prominent  than  those  giving  direct  evidence  of  disorder 
of  the  stomach. 

Course  and  Prognosis. — The  disease  in  infancy  is  a  severe  one, 
particularly  if  it  has  been  of  long  duration.  Recovery,  however,  usually 
takes  place  under  proper  treatment.  The  earlier  this  can  be  instituted 
the  better  the  prognosis.  On  the  other  hand,  the  younger  the  infant  the 
less  chance  it  has.  The  occurrence  of  the  malady  in  bottle-fed  babies 
and  during  hot  weather  adds  greatly  to  the  danger.  Propitious  sur- 
roundings make  the  prognosis  more  favorable;  hospital  babies  being 
notable  for  the  liability  to  contract  the  disease  and  for  the  high  death-rate. 
The  course  is  always  tedious  and  relapses  are  very  prone  to  occur,  with- 
out there  being  any  discoverable  reason  for  this  in  the  character  of  the 
food  given.  Finally  the  disease  is  dangerous  in  infancy  in  the  predisposi- 
tion it  creates  to  the  development  of  diarrheal  disorders,  rachitis,  and 
infantile  atrophy. 

In  older  children  the  prognosis  is  more  favorable  so  far  as  life  is  con- 
cerned, although  the  gastritis  is  liable  to  be  long-continued,  and  the  tend- 
ency to  relapse  may  last  for  years  and  perhaps  never  entirely  disappear. 

Diagnosis. — This  is  usually  easy,  if  the  history  of  the  case  is  known. 
In  infants  the  onset  of  tuberculous  meningitis  is  sometimes  marked  only  by 
vomiting,  lasting,  it  may  be,  a  number  of  weeks,  and  confusion  may  arise. 
As  a  rule  the  recognition  is  readih^  made  after  a  short  interval,  menin- 
gitis showing  other  characteristic  symptoms.  Stenosis  of  the  pylorus  may 
also  readily  simulate  a  chronic  gastritis.  This  is  particularly  the  case 
when  the  obstruction  has  not  been  absolute,  the  disease  has  continued 
some  time,  and  gastric  dilatation  has  developed.  Generally  a  careful 
study  will  distinguish  between  the  two  diseases.  The  active  gastric 
jieristalsis  and  the  usual  prompt  and  violent  projectile  vomiting  after 
taking  food  characterize  stenosis,  especially  early  in  the  case.  The  com- 
bination of  emaciation  and  cough  may  suggest  tuberculosis  in  older  chil- 
dren; but  the  aVjsence  of  any  localizing  evidences  of  tuberculosis  is  an 
indication  opposed  to  the  existence  of  this  disease. 

Treatment.  Infants. — Treatment  requires  all  the  thought  and  skill 
possible  on  the  part  of  the  physician,  since  it  must  vary  with  the  indi- 
vidual case.  Prophylaxis  is  much  easier  than  cure,  and,  on  the  first 
warning  of  danger,  as  through  the  repeated  development  of  gastric  dis- 
turljance,  most  careful  scmucIi  must  be  made  for  the  cause  of  this,  which 
is  oftenest  a  dietetic  one;  and  this  removed  before  the  condition  becomes 
established.  Overfeeding  being  of  much  more  common  occurrence  than 
underfeeding,  it  is  probal)le  that  the  cause  will  be  found  here;  either  in 
too  great  a  total  amount  of  food  given,  or  in  one  too  rich  in  some  particu- 
lar. In  many  cases  the  diet  is  one  entirely  unsuited  to  the  infant  in 
question,  however  fitting  it  may  have  pioved  for  others.  The  effort  so 
often  made  to  feed  cliihh-en  by  a  fixed  rule  is  a  fertile  source  of  chronic 
digestive  disorder. 

With  the  disease  already  established,  again  the  search  must  be  for  the 
cause,  and  this  is  often  a  Uiost  difficult  pr()l)leni  for  .solution.  The  whole 
past  dietetic  history  must  l:)e  reviewed.  This  will  probably  make  clear 
the  origin  of  the  disturbance.  Perhajjs  most  frequently  the  fault  will 
be  found  in  an  excess  of  or  an  intolerance  for  the  fats.  In  such  cases  bene- 
fit may  often  be  obtained  by  giving  a  fat -free  mixture,  using  skimmed 
milk  as  a  basis  for  this.     In  other  ca.ses,  although  much  less  freciucntly. 


726  THE  DISEASES  OF  CHILDREN 

the  protein  occasions  difficulty.  In  this  event,  peptonizing  may  be  of 
service,  or  tlie  administration  of  casein-free  milk  in  the  form  of  whey. 
The  latter  is,  indeed,  an  invaluable  remedy  in  many  instances,  but  is  too 
weak  a  food  for  long  continuance.  It  should  be  made  from  skimmed 
milk  when  it  is  desired  to  avoid  fat  entirel3^  Often  a  diet  with  high 
protein-percentage  and  diminished  fat-percentage  as  obtained  is  ser- 
viceable b}^  the  use  of  some  of  the  numerous  "albumin  milks,"  or  ''casein 
milks"  recommended  (p.  148).  Buttermilk  is  a  valuable  remedy  in 
such  instances,  being  a  fat-free  food  in  which  the  protein  is  in  high  per- 
centage, already  coagulated  and  broken  up  into  a  fine  flocculent  state. 
The  addition  of  a  cereal  and  sugar,  as  commonly  advised  (p.  147),  adds 
to  its  caloric  value.  In  some  instances  the  sugar  of  milk  may  give  occa- 
sion to  fermentation  and  produce  the  disease.  In  such  its  amount  must 
be  reduced,  or  cane-sugar  or  dextrine-maltose  preparations  tried  as  a 
substitute.  Many  cases  show  entire  intolerance  for  milk  for  a  time,  and 
in  these  the  food  may  temporarily  be  albumen  water  or  a  cereal  decoction 
such  as  barley  water.  As  this  is  not  sufficient  to  sustain  life  indefinitely, 
a  plan  often  useful  is  to  fortify  it  after  a  time  by  the  addition  of  whey 
made  from  skimmed  milk,  and  later  by  peptonized  skimmed  milk  in  small 
amounts  gradually  increased.  In  other  cases  a  cereal  decoction  may  be 
partially  dextrinized  (p.  155) ;  and  to  this  milk  be  finally  added  in  increas- 
ing amounts.  Malt-soup  (p.  156)  is  often  especially  useful  in  such  in- 
stances. In  still  other  cases  the  fault  is  an  excess  of  starchy  food,  and 
the  chief  dietetic  treatment  consists  in  the  decided  reduction  of  the 
amount  given. 

It  is  usually  of  benefit  in  beginning  treatment  to  make  a  very  radical 
change  from  the  food  which  had  been  given.  Whatever  diet  may  be 
selected,  the  first  effort  must  be  to  bring  about  a  cessation  of  the  vomiting 
and  other  evidences  of  the  disease;  but  without  striving  for  a  gain  of 
weight.  Merely  to  stop  the  loss  is  all  that  is  required  for  a  while.  After 
a  time,  however,  the  failure  to  gain  properly  becomes  a  matter  of  im- 
portance. The  food  which  has  been  agreeing  is  probably  much  below 
the  normal  caloric  value  required,  and  a  very  gradual  return  to  a  stronger 
diet  is  then  imperative.  In  fact,  it  is  necessary  to  have  constantly  in 
mind  the  caloric  requirements  to  make  gain  possible,  at  the  same  time 
not  forcing  any  element  of  food  to  an  extent  which  disagrees,  since  this 
brings  on  relapse  and  retards  recovery.  The  effort  should  be  made  to 
return  to  a  milk-modification  containing  fat  as  soon  as  this  can  be  done 
with  safety. 

Apart  from  the  composition  of  the  food  its  method  of  administration 
is  important.  Some  infants  do  better  on  small  amounts  of  more  con- 
centrated nourishment;  others  on  larger  quantities  more  diluted.  As  a 
rule  the  interval  should  be  long,  but  only  trial  will  show  whether  feeding 
frequently  at  short  intervals  and  in  small  amounts  may  not  be  better. 
In  some  cases  food  given  by  gavage  will  be  retained  when  that  taken  in 
the  ordinary  way  is  not.  In  such  instances  it  should  usually  be  in  larger 
amount,  often  with  advantage  peptonized,  and  administered  perhaps  but 
3  times  daily.  At  times  the  loss  of  appetite  is  so  great  that  gavage  must 
be  used  to  sustain  life,  the  infant  refusing  all  food  offered  to  it  in  the  usual 
manner.  In  the  line  of  diet  there  is  often  nothing  so  good  for  young 
infants  with  chronic  gastritis  as  the  employment  of  a  wet-nurse. 

In  addition  to  the  correction  of  diet,  lavage  of  the  stomach  is  a  most 
useful  remedial  measure.  This  should  be  performed  once,  or  sometimes 
twice,  daily;  later  less  frequently,  using  a  normal  salt-solution  or  a  1  per 


CHRONIC  GASTRITIS— CHRONIC  GASTRIC  INDIGESTION       727 

cent,  solution  of  bicarbonate  of  soda.  Without  lavage  it  is  impossible 
to  get  rid,  to  a  satisfactory  extent,  of  the  tenacious  mucus,  which  other- 
wise interfers  greatly  with  the  access  of  the  digestive  secretions  to  the  food 
taken.  Lavage  is  best  performed  2  to  3  hours  after  a  feeding.  Some- 
times it  is  of  benefit  to  give  food  by  gavage  while  the  tube  is  in  position 
for  gastric  washing ;  in  other  cases  better  results  are  obtained  by  giving  no 
nourishment  for  2  hours  after  the  washing  has  been  performed.  Lavage 
is,  as  a  rule,  well  tolerated  by  infants,  and  mere  feebleness  is  not  a  contra- 
indication; but  in  any  infant  in  whom  it  produces  severe  nausea,  vomit- 
ing, prostration,  or  cyanosis,  it  should  be  employed  with  great  caution 
or  abandoned. 

The  administration  of  drugs  plays  a  very  secondary  part  in  the  treat- 
ment of  chronic  gastritis.  Bismuth  is  sometimes  useful  in  controlling 
the  vomiting,  and  occasionally  it  vasiy  well  be  combined  with  minute 
doses  of  calomel,  or  with  benzoate  or  bicarbonate  of  soda.  In  other 
instances  a  mixture  of  soda,  bismuth  and  spearmint  water  is  of  value  in 
neutralizing  acidity  and  dislodging  accumulated  gas.  Tincture  of  nux 
vomica  may  be  administered  with  soda  in  cases  where  there  is  great  loss 
of  appetite.  Occasionally  dilute  hydrochloric  acid  with  pepsin  is  of 
service,  particularly  where  examination  of  the  gastric  contents  shows 
diminution  of  the  gastric  secretion.  Constipation  must  be  overcome  by 
laxatives,  especially  citrate  of  magnesia  or  milk  of  magnesia.  Measures 
directed  to  the  improvement  of  the  general  health  must  not  be  forgotten. 
Among  these  are  the  maintenance  of  the  body-temperature,  if  below 
normal;  the  exposure  to  abundant  fresh  air  out  of  doors  or  in  a  sun-par- 
lor; massage;  bodily  rest;  careful  handling  after  feeding,  and  the  avoid- 
ance of  all  excitement. 

Older  Children. — Prophylaxis  is  as  important  here  as  in  infancy,  but 
difficult  on  account  of  the  irregularity  of  symptoms  and  the  often  insidious 
onset.  In  the  treatment  of  the  disease  itself,  not  only  is  the  diet  to  be 
carefully  regulated,  but  other  matters  equally  important  cared  for.  Late 
hours,  undue  mental  excitement  or  strain,  bodily  fatigue,  too  long  school- 
hours,  lack  of  fresh  air  and  exercise,  and  other  possible  etiological  factors 
must  necessarily  be  corrected  in  order  to  obtain  benefit,  since  so  much 
of  the  chronic  indigestion  is  of  functional  origin.  Change  of  climate  is 
often  of  great  benefit.  Rest  recumbent  for  an  hour  daily  is  of  service. 
No  food  should  be  allowed  between  meals  and  the  diet  should  be  plain 
and  digestible,  all  highly  seasoned  dishes,  pastry,  puddings,  cakes  and 
sweet-meats  being  avoided.  No  fried  food  whatever  can  be  allowed,  and, 
as  a  rule,  but  a  limited  amount  of  carbohydrate  given.  The  diet  should 
consist  largely  of  lean  meats;  milk  not  too  rich,  or  preferably  koumys  or 
other  fermented  milk,  or  buttermilk;  small  amounts  of  toast  or  zwieback; 
and  later  green  vegetables  carefully  tried  in  small  amounts.  The  in- 
crease of  carbohydrate  vegetables  should  be  made  slowly  and  cautiously 
until  recovery  is  well  advanced.  Thorough  mastication  is  important. 
In  severe  cases  a  diet  purely  of  milk,  modified  in  some  way  and  often 
with  the  fat  largely  removed,  may  be  required  for  a  time,  while  in  others 
milk  may  need  to  be  withdrawn  entirely.  Tonic  remeilies  are  often  of 
benefit,  tincture  of  nux  vomica  being  most  useful  before  food,  combined 
sometimes  with  soda  and  with  gentian.  At  times  hydrochloric  acid 
after  food  is  better,  if  the  tongue  remains  heavily  coated.  If  vomiting 
is  troublesome  bismuth  or  the  coml)ination  of  liquor  calcis  and  aqua 
cinnamomi,  previously  referred  to  (p.  720)  may  be  of  service.  Chronic 
constipation  must  be  relieved  by  appropriate  remedies.     Sometimes  the 


728  THE  DISEASES  OF  CHILDREN 

addition  of  small  amounts  of  an  aromatic,  such  as  tincture  of  ginger, 
relieves  pain  by  causing  displacement  of  accumulated  gas.  Constant 
care  for  the  general  hygiene  and  the  diet  is  required  often  for  years,  in 
order  to  avoid  the  great  tendency  to  relapse. 


CHAPTER  V 

DISEASES  OF  THE  STOMACH  AND  INTESTINES  (CONTINUED) 

TYMPANITES 

Distention  of  the  intestine  and  stomach  with  gas  is  a  symptom  which 
may  attend  various  diverse  conditions,  and  in  many  instances  becomes 
the  most  important  one  demanding  special  treatment.  It  may  depend 
directly  upon  digestive  disturbance,  being  one  of  the  most  prominent 
symptoms  of  chronic  intestinal  indigestion,  and  due  to  the  fermentation 
of  food  especially  of  an  amylaceous  nature.  It  is  a  very  constant  and 
pronounced  symptom  in  acute  peritonitis  and  sometimes  in  appendicitis, 
the  result  in  each  case  of  a  temporary  paratysis  of  the  intestinal  wall. 
Tuberculous  peritonitis  is  likewise  attended  by  it.  Typhoid  fever 
exhibits  it  at  times,  especially  in  older  children,  but  seldom  to  the  extent 
seen  in  adult  life.  In  pneumonia  it  is  sometimes  excessive  and  consti- 
tutes a  serious  symptom  with  a  grave  prognostic  import.  Rachitis 
constantly  is  attended  by  tympanitic  distention  of  the  abdomen,  de- 
pendent partly  upon  the  accompanying  intestinal  catarrh  and  partly 
upon  the  weakened  abdominal  and  intestinal  walls.  Finally  congenital 
dilatation  of  the  colon  is  characterized  by  a  remarkable  dilatation  of 
the  intestine  by  gas. 

The  treatment  consists  on  the  one  hand  of  the  cause,  and  on  the 
other  is  symptomatic,  intended  to  relieve  the  distress  often  present.  In 
the  latter  category  are  such  measures  as  turpentine  stupes  externally;  in- 
testinal douching;  the  use  of  the  rectal  tube,  which  may  be  allowed  to 
remain  in  position  even  for  some  hours  if  needed;  the  administration  of 
carminatives  and  of  asafetida;  and  in  very  urgent  cases  the  hypodermic 
administration  of  eserine.  I  have  obtained  success  with  this  last  when 
other  measures  had  failed  in  very  threatening  conditions.  As  it  is, 
however,  a  remedy  which  can  exercise  a  powerful  depressing  influence 
it  may  well  be  combined  with  strychnine. 

Opium,  although  a  reliever  of  pain,  should  be  given  cautiously  when 
tympanites  is  present,  since  it  is  likely  to  increase  the  distention  by 
diminishing  intestinal  peristalsis. 

INTESTINAL  COLIC 

(Enteralgiaj 

Although  but  a  symptom,  colic  is  one  so  important  and  frequent, 
especially  in  infancy,  that  it  deserves  separate  consideration.  In  the 
narrower  sense  it  consists  in  the  occurrence  of  intestinal  pain  in  paroxysms, 
depending  sometimes  on  distention,  oftener  upon  a  spasmodic  contraction 
of  the  muscular  wall  of  the  intestine.  This  paroxysmal  nature  distin- 
guishes it  from  the  more  persistent  pain  which  may  accompany  any  in- 
flammatory condition  of  the  intestine  or  peritoneum,  or  some  nervous 
disorder,  and  which  is  to  be  included  under  the  broader  title  of  enteralgia. 


INTESTINAL  COLIC  729 

Etiology. — Among  the  various  causes  the  most  common  is  anj^  form 
of  intestinal  indigestion  with  the  resulting  production  of  gas.  This  is 
observed  with  especial  frequency  in  the  first  3  or  4  months  of  life,  and 
occurs  in  breast-fed  babies  as  well  as  others,  even  when  analysis  of  the 
breast-milk  shows  nothing  abnormal.  The  addition  of  starch  to  the 
diet  is  a  fertile  source  of  pain  in  many  bottle-fed  children,  although  any 
of  the  elements  of  the  milk  itself  may  produce  it.  In  older  children 
cohc  may  attend  acute  intestinal  indigestion  from  the  eating  of  green 
fruits  and  other  unsuitable  substances. 

Many  cases  of  colic  appear  to  have  a  nervous  origin,  brought  about 
reflexly  as,  for  example,  through  chilling  of  the  surface  of  the  body. 
The  ingestion  of  certain  poisonous  substances,  such  as  lead  or  arsenic, 
may  produce  intestinal  pain.  This  is  very  uncommon  in  infancy,  but  an 
analogous  condition  occasionally  follows  from  the  nursing  of  breast-milk 
which  has  been  secreted  under  disturbed  psychic  influences.  Purgative 
drugs  are  also  a  frequent  source  of  pain  in  the  intestine.  Peritonitis, 
enteritis  of  anj^  form,  appendicitis,  intussusception,  and  any  condition 
which  produces  tympanites  may  be  productive  of  enteralgia. 

Symptoms. — In  enteralgia  in  general  the  chief  symptom  is  abdominal 
pain  which  arises  in  the  intestine.  In  true  colic  this  is  paroxysmal. 
The  infant  may  exhibit  other  symptoms  of  indigestion;  but  very  fre- 
quently, especially  in  breast-fed  babies,  it  is  healthy  and  thriving  except 
for  the  colic.  The  attack  begins  more  or  less  suddenly,  perhaps  after  a 
short  period  of  discomfort.  The  cry  is  very  loud  and  unceasing;  the 
face  is  congested  and  often  somewhat  cyanotic,  or  with  pallor  about  the 
mouth ;  the  abdomen  is  distended  and  tense ;  the  legs  are  now  drawn  up 
upon  the  abdomen,  now  momentarily  extended;  the  feet  are  often  cold; 
the  hands  are  clenched  and  the  arms  flexed  and  drawn  to  the  bod3\  The 
paroxysm  continues  a  variable  time,  sometimes  several  hours  with  com- 
plete or  partial  intermissions  lasting  for  a  few  moments  only.  Finally 
with  the  expulsion  of  gas  or  feces  the  symptoms  disappear  completely 
and  the  infant  falls  asleep.  If  the  colic  has  been  prolonged  and  intense 
quite  a  degree  of  prostration  may  follow.  In  many  instances  the  symp- 
toms are  not  nearly  so  severe  and  the  baby  is  merely  fretful  and  wakeful 
until  relieved.  In  others,  with  highly  sensitive  nervous  sj\stems,  con- 
vulsions may  develop. 

The  frequency  of  the  occurrence  of  colic  varies  greatly.  In  many 
it  is  only  occasional,  but  in  others  in  the  first  few  months  of  life  it  seems 
oftener  present  than  absent,  and  is  especially  liable  to  occur  in  the  night- 
time; with  the  result  that  the  parents,  as  well  as  the  infant,  ol)tnin 
almost  no  sleep.  It  is  a  noteworthy  fact  that  whereas  every  one  in 
attendance  seems  exhausted  on  the  next  day,  the  infant  often  appears 
none  the  worse  for  its  experience. 

Diagnosis. — This  is  easy  in  most  cases  if  the  attack  is  seen  by  the 
physician.  Oftener,  however,  it  is  difficult  if  dependence  must  be  placed 
entirely  on  a  description  given  by  the  mother  or  lun'se.  Colic  is  espe- 
cially to  be  distinguished  from  iumger.  The  cry  of  the  former  is  generally 
sharper,  more  violent,  and  more  paroxysmal;  that  of  the  latter  more 
persistent  and  often  more  fretful.  Fre(|uently  the  infant  with  colic 
refuses  food;  in  other  cases  il  will  take  it  well  if  the  pain  is  not  too  severe, 
and  may  be  tcunporarily  relieved  by  it.  Soon,  however,  the  cry  returns 
in  full  force,  thus  exchuling  completely  the  diagnosis  of  hunger.  Plarache 
causes  very  ])ersistent  screaming,  and  there  is  tenilerness  about  the  ear. 
The  pain  of  peritonitis  and  appendicitis  is  to  he  distinguished  from  colic 


730  THE  DISEASES  OF  CHILDREN 

by  the  more  persistent  character  and  bj^  other  attendant  symptoms, 
especially  the  tenderness  on  pressure.  In  colic  gentle  pressure  is  often 
a  source  of  relief.  The  pain  of  intestinal  colic  is  often  difficult  to  differ- 
entiate from  that  of  gastralgia,  which,  indeed,  it  may  attend,  or 
with  which  it  may  alternate.  Older  children  refer  the  pain  of  gastralgia 
to  the  epigastrium.  In  infancy  relief  of  pain  by  expulsion  of  gas  from 
the  rectum  indicates  that  the  disturbance  was  in  the  large  intestine, 
which  is  the  most  common  situation. 

Treatment. — The  occurrence  of  the  disease  must  be  prevented, 
as  far  as  possible,  by  a  careful  stud}''  of  the  diet,  and  a  change  in  this  if  it 
is  found  necessar}^  Whether  advisable  or  not  depends  upon  the  fre- 
quency and  severity  of  the  paroxysms  and  upon  the  general  health  of 
the  infant  in  other  respects.  If  an  infant  is  thriving  upon  its  mother's 
milk,  except  for  frequent  attacks  of  pain,  and  the  milk  is  found  on  anal- 
ysis to  be  practically  of  normal  composition,  it  is  usually  better  to  tem- 
porize, and  to  give  what  relief  is  possible  when  pain  is  present,  merely 
altering,  perhaps,  the  intervals  and  length  of  nursings;  especially  since 
the  tendency  is  for  colic  to  lessen  greatly  after  the  first  4  months  of  life. 
In  such  infants  must  be  considered  the  possibility  of  the  pain  being  largely 
neuralgic  rather  than  due  to  indigestion;  and,  in  any  event,  weaning 
threatens  more  serious  dangers  than  the  colic  presents.  Should,  however, 
the  infant  be  manifestly  losing  health,  weaning  is  to  be  recommended; 
and  in  bottle-fed  babies  with  severe  colic  some  change  in  the  diet  is 
certainly  advisable.  The  prevention  of  attacks  is  also  to  be  attained 
by  avoiding  chilling  of  the  surface,  by  seeing  that  the  bowels  are  opened 
regularly,  and  especially  that  a  movement  is  obtained  shortly  before 
the  time  of  day  when  the  pain  comes  on  or  is  worst.  An  enema  may  be 
used  for  this  purpose.  Giving  a  carminative  such  as  sodamint  or  some 
modification  of  it  before  the  meals  is  also  often  a  useful  preventive 
measure. 

During  the  paroxysm  a  hot  application  should  be  placed  on  the 
abdomen,  such  as  a  hot  water  bag,  weak  mustard  plaster,  turpentine 
stupe,  or  spice  plaster.  This  tends  to  relax  the  spasmodic  contraction 
of  the  intestinal  muscles.  Rubbing  the  abdomen  with  the  warm  hand 
is  often  of  service.  One  of  the  best  remedies  is  the  giving  of  an  enema, 
since  this  starts  the  peristalsis  and  causes  an  expulsion  of  feces  and  of 
gas.  The  injection  may  consist  of  soap  and  water,  using  6  or  8  ounces 
(177  or  237)  or.  more  according  to  the  age  of  the  child  (p.  234).  Inter- 
nally carminatives  are  useful,  not  onl}^  because  they  are  effectual  in 
producing  eructation  of  the  gas,  should  the  condition  be  one  of  gastric 
distention  and  spasm  rather  than  intestinal  colic,  but  because  in  the 
latter  condition  they  act  reflexly  from  the  stomach,  increasing  the  in- 
testinal peristalsis  and  causing  the  gas  to  be  expelled  from  the  bowel 
Bicarbonate  of  soda  may  be  given  with  spearmint-water,  peppermint- 
water,  or  fennel-water.  In  more  severe  cases  in  young  infants  the  addi- 
tion of  the  bromides  (1  to  2  gr.)  (0.07  to  0.13),  or  of  chloral  (K  gr-) 
(0.016)  is  very  effective  in  relaxing  the  muscular  spasm.  Mistura 
asafetida  (10  m.)  (0.62)  or  spir.  aether,  com/p.  (4  to  5  m.)  (0.25  to 
0.31)  is  often  very  serviceable.  In  the  worst  cases  opiates  should 
be  used;  yet  bearing  in  mind  that  if  the  colic  is  due  to  flatulent 
dyspepsia  rather  than  to  a  purely  niervous  condition,  relief  follows 
but  peristalsis  is  inhibited,  constipation  occurs,  and  flatulence  may 
be  finally  increased. 


THE  FECES  IN  DIGESTIVE  DISEASES  731 

THE  FECES  IN  DIGESTIVE  DISEASES 

In  older  children  the  character  of  the  abnormal  stools  varies  with 
the  food  taken;  meat-fibre,  vegetable  material,  milk,  and  the  like  showing 
themselves  in  different  degrees.  ^NIucus,  too,  may  be  in  large  amount, 
especially  in  some  forms  of  chronic  intestinal  indigestion  and  in  colitis. 
The  following  description  apphes  especially  to  the  stools  of  infants: 

The  normal  stool  of  the  breast-fed  infant  is  mustard-yellow  in  color, 
smooth,  with  no  evidences  of  undigested  food,  and  slightly  acid.  (See 
p.  46,  Fig.  12.)  In  healthy  artificiallj^  fed  children  the  shade  of  color  is 
often  somewhat  lighter,  depending  upon  the  amount  of  fat  in  the  food;  a 
high  percentage  of  this  producing  a  paler  stool.  At  the  most  there  may 
be  small,  scattered  white  masses  of  undigested  fat.  In  older  infants  the 
yellow  is  somewhat  deeper  and  the  stools  more  salve-like  in  consistency. 

Mucous  Stools.— In  cases  where  food  has  been  withdrawn  for  a 
day  or  two,  the  stools  consist  of  the  thin  mucoid  secretion  of  the  in- 
testine stained  a  brownish  tint  (hunger  stools).  After  a  purgative,  es- 
pecially castor  oil,  a  large  amount  of  mucus  is  passed  in  infancy,  wrongly 
supposed  by  the  mother  to  have  been  present  before  the  oil  was  adminis- 
tered. Mucus  occurs  readily,  too,  in  many  disturbances  of  the  digestive 
tract  in  early  life,  and  may,  at  first,  if  continuing  but  a  short  time,  in- 
dicate either  an  inflammatory  or  a  functional  disturbance  of  the  large 
intestine.  If  it  is  persistent,  it  points  rather  to  inflammation.  Un- 
digested starch  has  a  certain  similarity  in  appearance  to  mucus,  but  can 
be  distinguished  from  it  by  the  iodine  reaction.  Stools  composed  almost 
entirely  of  blood-stained  mucus  occur  in  dysenteric  conditions  and  in 
intussusception. 

Protein  Stools. — These  are  seen  in  infants  especially  where  the 
protein  of  the  food  is  of  high  percentage  and  undigested.  The  odor  of 
putrefaction  is  discoverable  at  times,  combined  with  an  alkaline  reaction. 
The  color  is  brownish-yellow,  and  mucus  is  always  present.  Sometimes 
tough,  yellowish  protein-curds  are  found  (Fig.  243). 

Fatty  Stools. — Fat  may  show  itself  either  as  soap;  or  in  the  form  of  a 
smooth,  yellow  stool;  or  as  soft  white  curds  composed  of  neutral  fat. 

The  soap  stool  depends  upon  a  large  excess  of  fatty  acids,  combined 
with  calcdum  or  magnesium  to  form  a  soap.  They  are  white  or  grey, 
shiny,  fairly  firm,  homogeneous,  crumbly  or  salve-like,  of  acid  reaction, 
and  have  a  rancid  or  sour  odor  (Fig.  244).  They  are  commonly  com- 
bined with  more  or  less  protein,  and,  if  this  is  in  large  amount,  the  odor 
is  cheesy  or  offensive  from  the  decomposition  of  this,  and  the  reaction 
may  be  alkahne. 

The  fatty  stool  is  of  a  bright-yellow  color,  soft,  and  of  greasy  appear- 
ance, and  will  produce  a  grease  spot  if  placed  upon  paper.  It  contains 
a  large  amount  of  neutral  fat  and  fatty  acids.  The  stools  are  thin,  and 
may  be  frequent  enough  to  produce  a  fatty  diarrhea. 

The  curdy  stool  exhibits  numerous  large  or  small  curds,  and  is  of  an 
acid  reaction.  The  curds  are  generally  soft,  white,  and  composed  of  fat. 
They  are  to  be  distinguished  from  the  yellow  curds  consisting  of  proteid 
material  and  already  referred  to.  The  stool  as  a  whole,  apart  from  the 
white  lumps,  is  of  a  green  or  yellowish  color  and  often  diarrheal,  and  mucus 
is  always  present  (Fig.  245).  The  presence  of  curdy  stools,  as  also  of 
soap  stools,  is  a  matter  of  little  clinical  consequence  unless  symptoms 
of  indigestion  arc  present  (Tall)ot).^ 

iBost.  Med.  and  Surg.  .luur.,  1918,  CLXXIX,  35. 


732  THE  DISEASES  OF  CHILDREN 

Carbohydrate  Stools. — Very  often  the  stool  of  this  nature  is  of  a 
normal  consistence,  homogeneous,  smooth,  and  of  a  brown  or  yellowish- 
brown  tint  and  acid  reaction  (Fig  246).  If  starch  has  been  adminis- 
tered, this  may  perhaps  be  found  with  the  iodine  test.  In  other  cases 
there  may  be  a  decomposition  of  the  carbohydrates  in  the  intestine,  pro- 
ducing thin,  frothy,  acid  stools,  often  green  in  color.  The  odor  is  then 
sometimes  that  of  acetic  acid. 

Green  Stools.— These  are  of  very  common  occurrence.  The  stool 
may  be  of  a  faint  pea-green  color  w^hen  passed,  or  may  become  so  shortly 
afterward.  This  probably  depends  upon  unaltered  biliverdin,  and 
evacuations  of  this  nature  are  not  to  be  considered  pathological.  In 
other  cases  the  color  is  of  a  deep  spinach-green,  seen  chiefly  in  the  mucus 
passed  in  the  stool  (Fig.  247).  In  some  cases  this  probably  depends 
upon  the  action  of  a  specific  microorganism.  These  green  stools  very 
frequently  have  present  the  white  curdy  masses  consisting  of  fat  already 
described.  Green,  watery  stools  are  often  seen  in  acute  intestinal  indi- 
gestion, both  in  breast-fed  and  artificially  fed  infants.  They  may  de- 
pend either  upon  an  excess  of  fat  or  of  sugar. 

Brownish  Stools. — As  stated,  these  are  quite  characteristic  of 
many  cases  where  food  containing  a  high  percentage  of  protein  or  of 
carbohydrate  (Fig.  246)  is  given.  Children  fed  on  whey  develop  brown- 
ish stools,  and  the  hunger-stools  referred  to  (p.  731)  have  a  similar 
tint. 

Blood  in  the  Stools. — This  is  not  necessarily  a  serious  matter. 
Any  moderate  congestion  of  the  mucous  membrane  of  the  large  intestine 
may  develop  streaks  of  blood  upon  the  mucus  passed  (Fig.  247).  Blood 
streaks  may  depend,  too,  upon  hemorrhoids  or  fissure  of  the  anus,  or  upon 
the  passage  of  a  large  constipated  movement.  Combined  with  a  consider- 
able amount  of  mucus,  blood  is  also  seen  in  intussusception  and  in  ileo- 
colitis. If  in  large  amount  and  coming  from  higher  in  the  alimentary 
canal,  the  stools  are  colored  a  reddish-black,  and  may  be  the  result  of 
ulceration  or  of  hemorrhage  from  other  causes.  The  condition  is  to  be 
distinguished  from  the  black  stools  dependent  upon  the  administration 
of  bismuth  or  iron. 

Intestinal  Sand.^ — Occasionally  minute  sand-like  bodies  are  found 
in  the  stools,  and  may  be  in  considerable  quantity.  They  may  be  visible 
when  the  passages  are  of  a  diarrheal  nature,  or  discoverable  only  after 
washing  and  straining  them  from  the  fecal  matter.  The  nature  of  the 
sand  would  seem  to  vary.  In  some  instances  it  has  appeared  to  con- 
sist of  the  woody  cells  from  the  banana;  in  others  it  is  of  a  crystalline 
nature,  probably  produced  in  the  process  of  digestion.  It  is  uncertain 
whether  any  symptoms  are  attendant  upon  the  presence  of  intestinal 
sand. 

Micro=chemical  Examination  of  the  Stools. — This  procedure  is 
an  aid  in  determining  the  nature  of  the  stools.  Starch  is  detected  by  the 
application  to  the  feces  on  a  glass-slip  of  a  little  diluted  Lugol's  solution, 
which  colors  the  granules  blue.  The  test  for  the  comparative  amount  of 
fat  and  its  nature  is  the  most  important.  The  following  description  is 
based  chiefly  upon  the  contributions  of  Talbot:^  A  minute  portion  of 
the  stool  is  placed  upon  a  glass-slip,  stained  with  a  saturated  95  per  cent, 
alcoholic  solution  of  Sudan  III  and  covered  with  a  cover-glass.  Another 
portion  is  similarly  stained  with  a  saturated  solution  of  carbolfuchsin, 

1  Arch,  of  Ped.,  1911,  XXVIII,  120.     Amer.  Journ.  Dis.  Child.,  1911,  I,  173. 


THE  FECES  IN  DIGESTIVE  DISEASES  733 

diluted  one-half  if  necessary.     The  following  table  shows  the  results 
obtained: 

stain  Neutral  fat  Fatty  acids  Soaps 

Sudan  III Drops  staining  red.  Drops  staining  red,  or     Do  not  stain. 

!    crystals  which  may  or 
j    may  not  stain. 


Carbolfuchsin. .  .  .    Do  not  stain.     Remain  :  Stain  brilUant  red.  i  Stain  dull  red. 

oil}^,  colorless  drops.  I 

After  this  examination  is  over,  a  drop  of  glacial  acetic  acid  is  allowed 
to  run  under  the  cover-glass  of  the  Sudan  III  slide,  and  gentle  heat  is 
appUed  until  bubbling  begins.  This  turns  the  neutral  fat  and  soap  into 
fatty  acids  in  the  form  of  large  red  drops  while  hot,  crystals  when  cold; 
and  an  idea  can  be  obtained  of  the  total  amount  of  fat  present.  Whether 
or  not  this  is  normal  may  be  estimated  as  follows: 

Entire  digestion  of  fat,  enlargement  about  400  diameters,  Sudan  III, 
followed  by  acid  and  heat  gives  only  1  to  3  fat-drops  in  the  field ;  normdl 
digestion  of  fat.  under  the  same  conditions,  gives  5  to  8  drops;  slight 
excess  of  fat,  gives  8  to  10  drops;  moderate  excess  of  fat,  gives  over  12  drops; 
Large  excess  of  fat,  practically  the  whole  slide  is  filled  with  fat-drops. 

Talbot,^  however,  is  of  the  opinion  that  the  micro-chemical  examina- 
tions of  the  stools  is  usually  of  little  importance  unless  attended  by 
manifest  symptoms. 

DIARRHEAL  DISORDERS 

Like  vomiting  diarrhea  is  only  a  symptom,  but  one  of  such  importance 
that  a  review  of  its  various  causes  and  characteristics  is  necessary.  It 
is  one  of  the  most  frequent  and  often  most  serious  of  the  disorders  of  child- 
hood and  especially  of  infanc3^  The  part  which  it  plays  in  the  general 
mortality  of  early  hfe  has  already  been  referred  to  to  some  extent  (pp.  213- 
216).  Hermann-  estimated  that  more  than  33  per  cent,  of  the  deaths  in 
the  1st  year  of  life  occurring  in  Berlin  were  the  result  of  digestive  diseases, 
chiefly  diarrheal.  According  to  the  statistics  given  by  Still,''  from  2000 
to  4000  infants  under  1  year  of  age  died  annually  in  London  froui  diar- 
rheal diseases,  or  18.88  per  cent,  of  90,823  total  deaths  in  the  1st  year  of 
life  during  a  period  of  5  years  observation.  The  deaths  from  diarrheal 
disease  as  compared  with  other  affections  of  children  is  well  shown  in  the 
diagram  given  under  the  Causes  of  Death  (p.  216,  Fig.  31). 

Etiology.— A^c  is  consequently  a  predisposing  factor  of  imi)ortance. 
the  great  majority  of  cases  occurring  in  the  first  2  j'ears  of  life,  ant!  the  tend- 
ency to  the  disease  diminishing  greatly  after  this  period.  Season,  too,  is 
a  very  important  matter,  the  summer  being  the  time  of  year  in  which  the 
greater  number  of  cases  occur.  .  The  incidence  and  the  mortality,  indeed, 
seem  often  directly  proportionate  to  the  heat  of  the  weather  (Fig.  248). 
(See  also  p.  213,  Fig.  30.)  Poverty,  crowding,  undeanliuess,  and  pre- 
viously' debilitated  health,  such  as  prevail  so  extensively  aiuoiig  the  poor 
children  of  cities,  are  hygienic  factors  of  great  importance,     'i'he  inHuence 

1  Bost.  Med.  and  Surg.  Journ.,  1918,  CLXXIX,  li'). 

2  Zeitschr.   f.  Sociulwissenschaft,  VII,  4,   2;i8.      Hof.,    lOlti-rt.   .lalirl).   f.   Kiiidcrh., 
1905,  LXI,  .')()0. 

'  Connnon  Disorders  and  Diseases  of  Childliood.  1909,  210. 


734 


THE  DISEASES  OF  CHILDREN 


A. 


DIRECT     COMPUTATION 

191r3 


62:3 
fi0    70      70    SO    RnftO90tlOQ 


34.9 


H 


1 


60.7 
BO  70     70  SO    80  90    90»100 


1314 


33.8 


of  the  die  in  the  1st  year  of  hfe  is  of  especial  significance.  As  ah-eady 
stated  (see  MortaUty,  p.  212),  the  Habihty  to  death  is  far  greater  among 
the  artificially  fed  infants,  and  this  is  particularly  true  when  the  food  is 
improperly  prepared  or  contains  bacteria.  Other  diseases  frequently 
have  diarrhea  as  one  of  the  chief  or  secondary  symptoms.  This  is  true 
of  the  acute  infectious  diseases,  especially  typhoid  fever  and  of  measles, 
but  sometimes  also  of  scarlet  fever,  diphtheria,  poliomyelitis,  pneu- 
monia, septicemia,  and  others.  In  addition  to  the  factors  mentioned, 
other  causes  of  various  sorts  may  be  operative,  and  a  classification  might 

be  made  accordingly;  but  inasmuch 
as  often  several  causes  are  combined 
in  one  case,  the  relationships  are  close, 
and  no  very  sharp  division  can  be 
drawn.  From  a  pathological  stand- 
point, also,  the  varieties  of  diarrhea 
are  intimately  related,  there  being  in 
all  a  functional  disturbance,  and  in 
the  severer  forms  an  organic  change  as 
well;  or  the  latter  developing  in  the 
later  stages  of  a  diarrhea  which  was 
at  first  only  functional  in  nature. 
Further,  in  all  periods  of  infancy  and 
childhood  diarrhea  is  accompanied 
by  an  increase  of  the  number  of 
bacteria  in  the  stools;  and  it  is  conse- 
quently difficult  to  determine  whether 
the  condition  is  then  the  result  of 
a  directly  infectious  influence  of  the 
germs  upon  the  mucous  membrane, 
or  of  their  action  in  causing  decom- 
position in  the  food,  with  consequent 
production  of  toxic  substances;  or 
whether  the  increase  of  germs  is  sec- 
ondary to  a  simple  disturbance  of 
function  of  which  the  diarrhea  is  a 
symptom.  In  fact  from  every  stand- 
poiirt  it  is  often  quite  impossible  to 
distinguish  with  certainty  the  differ- 
ent forms  of  diarrheal  affections,  or 
to  understand  their  mode  of  produc- 
tion. Quite  commonly,  too,  diarrhea 
is  associated  with  gastric  disturbance  of  a  similar  origin  and  nature,  the 
causative  influence  being  something  ingested  which  disorders  the  stomach 
first  and  then  passes  into  the  bowel ;  or  both  regions  being  affected  at  the 
same  time  and  each  to  a  degree  which  varies  with  the  individual  case. 
The  following  classification  maj'  be  employed  as  a  matter  of  con- 
venience : 

1.  Diarrhea  Due  to  Locally  Acting  Mechanical  or  Chemical  Causes. — 
These  two  factors  are  so  closely  alhed  in  their  action  that  they  may  be 
considered  together.  Purely  mechanical  causes  are  those  which  induce 
increased  secretion  and  peristalsis  through  their  mechanical  irritation. 
The  presence  of  a  large  mass  of  undigested  food  in  the  intestine  may  act 
in  this  way.  This  is  particularly  true  if  the  diet  has  consisted  of  such 
substances  as  unripe  fruits;  green  corn;  tough  vegetable  matter,  such  as 


11.8 


Fig.  248. — Diagram  Showing  the 
Relation-  of  Heat  to  the  Onset  of 
Diarrhea  Among  86  (1913)  and  136 
(1914)  Dispensary  Infants  in  St.  Louis. 

The  figures  above  the  vertical  col- 
umns give  the  percentage  of  the  total 
cases  which  developed  with  the  tempera- 
ture of  the  upper  line.  (Blcyer,  Jour. 
Amer.  Med.  Assoc,   1915,  LXF,  2161.) 


DIARRHEAL  DISORDERS  735 

asparagus  stalks  and  celery ;  food  containing  a  large  amount  of  not  easily 
digested  matter,  such  as  cabbage,  turnips,  grape-seeds  and  grape-skins, 
fig-seeds  and  the  like.  Certain  of  these  act  also  as  chemical  causes  of 
diarrhea.  This  is  probably  true,  for  instance,  of  unripe  fruit,  cabbage, 
plums  and  similar  substances.  In  infants  some  of  the  food  elements 
may  be  directly  injurious  to  the  digestive  functions.  As  the  result  of 
chemical  causes  is  to  be  classed,  also,  the  diarrhea  depending  upon  the 
action  of  medicines,  as  when  too  large  a  dose  of  some  purgative  sets  up 
an  irritation  which  lasts  beyond  the  ordinary  influence  of  the  drug. 

2.  Diarrhea  of  Toxic  Origin  (Acute  Gastroenteric  Intoxication). — 
This  depends  upon  the  direct  influence  upon  the  intestine  of  the  toxic 
substances  produced  b}^  the  agency  of  bacteria.  These  toxins,  it  is  true, 
are  also  absorbed  and  occasion  constitutional  symptoms  and  even  organic 
changes  in  the  organs;  yet  their  action,  so  far  as  diarrhea  is  concerned,  is 
a  local  one  and  is,  strictlj^  speaking,  of  a  chemical  nature,  producing 
functional  disturbances  together  with  a  degree  of  catarrhal  inflammation. 

In  theory  the  difference  between  this  and  the  preceding  class  of  cases 
is  that  bacterial  action  predominates  in  the  second  group.  In  the  first 
class  the  food  taken  may  be  irritating  and  act  directly  upon  the  intestine; 
in  the  other  the  bacteria  produce  chemical  changes  in  the  food  which  are 
irritating  to  the  mucous  membrane.  The  distinction,  therefore,  is  not 
a  sharply  defined  one. 

3.  Diarrhea  of  Nervous  Origin. — This  is  a  common  form  at  all  ages 
of  life.  To  be  placed  here  are,  for  example,  the  cases  due  to  such  causes 
as  chiUing  of  the  body,  the  action  of  very  hot  weather  upon  the  organism, 
emotional  excitement,  fatigue,  and  the  reflex  action  often  immediately 
following  the  taking  of  food  into  the  stomach. 

4.  Diarrhea  of  Acute  Intestinal  Indigestion. — This  is  a  form  of  very 
great  frequency.  It  belongs  partly  to  one  or  the  other  of  the  classes  just 
described,  and  like  them  is  dependent  chiefly  upon  a  functional  disturb- 
ance of  the  intestine. 

5.  Diarrhea  of  Metabolic  Origin. — ^Omitting  from  this  category  cases 
the  result  of  the  local  toxic  action  of  substances  upon  the  intestine,  diar- 
rheas of  this  class  are  in  reality  eliminative,  produced  b}^  the  efforts  of  the 
system  to  get  rid  of  some  poison  in  the  circulation.  Most  of  the'diarrheas 
seen  in  the  acute  infectious  diseases  are  of  this  sort.  Uremia  produces 
diarrhea  in  the  same  way. 

6.  Diarrhea  of  Inflammatory  Nature. — Here  the  condition  is  the  direct 
result  of  organic  intestinal  changes  and  the  irritation  and  disturbance  of 
function  which  these  occasion.  In  this  class  are  diarrheas  dependent 
upon  ileocolitis.  This  disease  frequently  belongs  primarily  to  the  group 
of  toxic  diarrheas,  the  disturbance  being  largely  functional;  but  later 
decided  inflammatory  changes  develop.  The  results  of  the  ulcerative 
lesions  of  tuberculous  enteritis  are  to  be  placed  also  in  the  category  of 
inflammatory  diarrhea. 

Symptoms  and  Treatment. — Acute  intestinal  indigestion,  acute 
gastroenteric  intoxication  and  ileocolitis  are  diseases  of  such  importance 
in  early  life  that  they  nmst  receive  separate  consideration.  Other 
forms  of  diarrhea  exhibit  symptoms  and  require  treatment  of  a  nature  in 
accordance  with  the  cause.  That  from  local  mechanical  or  chemical 
causes  is  attended  by  gastric  disturbance,  abdominal  pain,  and  often 
fever.  Unloading  of  the  bowel  by  a  freely  acting  purgative  is  required, 
as  is  the  temporary  withdrawal  of  food.  When  there  has  been  decided 
irritation  or  nmch  pain,  opiates  may  be  needed  later.     Diarrhea  of  nerv- 


736  THE  DISEASES  OF  CHILDREN 

ous  origin  has  few  symptoms  except  the  looseness  of  the  bowels.  It 
demands  the  removal  of  the  cause  in  order  to  prevent  recurrence  of  the 
attacks,  and  for  the  attack  itself  opium  may  be  given  promptly.  On 
the  other  hand,  in  diarrheas  of  an  eliminative  nature  no  opium  should  be 
administered  early  unless  the  condition  is  so  severe  that  exhaustion  is 
feared.  Nature's  efforts  at  elimination  must  not  be  interfered  with. 
Cases  of  diarrhea  of  any  sort  should  be  treated  by  rest  in  bed  if  at  all 
severe,  as  exercise  tends  to  prolong  the  attack.  Inasmuch  as  there  is 
a  large  loss  of  the  salts  of  the  body  in  severe  diarrhea,  hypodermoclysis 
with  normal  salt  solution  is  often  of  great  value  in  supplying  the  needed 
sodium  chloride  and  favoring  the  retention  of  liquid  in  the  system. 

ACUTE  INTESTINAL  INDIGESTION 

Under  acute  intestinal  indigestion  may  be  included  those  milder 
cases  of  digestive  disorder  dependent  upon  functional  disturbance  pro- 
duced in  various  ways,  in  which  the  local  symptoms  generally  predomi- 
nate, usually  with  little  if  any  evidence  of  any  toxic  involvement  of 
the  organism.  The  distinction  between  this  and  the  gastroenteric 
intoxication  to  be  next  described  is  one  chiefly  of  degree,  and  there  are 
intermediate  forms  which  unite  the  two  so  closely  that  a  division  can  be 
made  only  for  the  sake  of  convenience  of  study.  Acute  intestinal  indi- 
gestion is  also  quite  commonly  associated,  especially  in  infancy,  with  the 
acute  gastric  indigestion  already  considered.  It  corresponds  in  many 
respects  to  the  Dyspepsia  of  Finkelstein's  classification  (p.  698). 

Etiology. — Among  the  principal  causes  in  infancy  are  overloading 
of  the  gastrointestinal  canal  with  too  large  an  amount  of  food;  the  use 
of  a  diet  unsuited  to  the  patient,  such  as  an  excess  of  protein,  fat,  or  sugar; 
nervous  or  other  conditions  affecting  the  milk  of  the  mother;  and  influ- 
ences involving  the  digestive  power  of  the  infant,  such  as  undue  excite- 
ment, acute  diseases,  rachitis  and  the  like.  The  effect  of  hot  summer 
weather  is  especially  noteworthy  and  particularly  so  in  artificially  fed 
infants,  not  only  through  the  alteration  of  the  intestinal  contents  produced 
by  bacterial  growth,  but  through  the  direct  prostrating  effect  of  the  high 
air-temperature  upon  the  child's  digestive  powers.  In  older  children  are 
seen  such  causes  as  the  ingestion  of  unripe  fruits  or  indigestible  vege- 
tables; fatigue;  acute  illnesses;  chilling  of  the  skin;  very  hot  weather; 
and  similar  causes  temporarily  inhibiting  the  digestive  functions.  Some- 
times one  article  of  food  always  produces  diarrhea  in  a  certain  child, 
although  harmless  to  others.  This  may  be  true,  for  instance,  of  fish, 
shellfish,  certain  vegetables  or  fruits,  and  even  milk.  Bacteria  would 
appear  to  play  a  very  minor  role,  so  far  as  any  direct  effect  upon  the  intes- 
tinal mucous  membrane  is  concerned;  although  doubtless  their  action  in 
altering  the  character  of  the  food  taken  is  of  importance. 

Pathological  Anatomy. — There  are  no  lesions  other  than  con- 
gestion of  the  mucous  membrane;  but  the  action  of  the  etiological  agent, 
whether  directly  or  through  reflex  disturbance,  produces  an  increase  of 
the  intestinal  secretion  with  outpouring  of  liquid  from  the  vessels  and  an 
augmented  peristalsis,  all  resulting  in  diarrhea. 

Symptoms. — The  disease  is  usually  associated  with  gastric  symp- 
toms, especially  in  infancy,  the  noxious  agent,  if  of  the  nature  of  an  indi- 
gestible article,  exercising  its  action  upon  the  stomach  before  it  reaches 
the  intestine.  Consequently  in  this  event  the  attack  is  usually  ushered 
in  by  vomiting  of  short  duration ;  and  this  is  attended  or  soon  followed  by 
fever,  even  up  to  104°  or  105°F.  (40°  or  40.6°C.)  but  disappearing  generally 


ACUTE  INTESTINAL  INDIGESTION 


737 


within  24  hours;  sometimes  persisting  a  longer  time  (Fig.  249).  There 
are  intestinal  pain  (see  Colic,  p.  728) ;  often  distention  of  the  abdomen  by 
gas;  restlessness;  slight  prostration,  and  soon  diarrhea.  In  older  children 
the  symptoms  of  the  so-called  "bilious  dyspepsia"  are  present,  consist- 
ing of  loss  of  appetite;  nausea;  vomiting;  diarrhea;  headache;  occasion- 
ally slight  jaundice,  and  moderate  temporary  fever,  if  any.  The  amount 
of  urine  is  much  diminished  if  the  diarrhea  is  severe. 

The  stools  in  infancy  contain  undigested  milk  in  larger  or  smaller 
curdy  masses  in  a  watery  fluid,  sometimes  with  more  or  less  mucus,  but 
without  blood.  The  color  varies  from 
yellow  to  white  or  green,  the  latter 
depending  upon  unchanged  bihary 
coloring  matter  (bihverdin).  The 
stools  are  especially  liable  to  be  passed 
after  taking  food,  and  are  usually 
less  frequent  at  night.  The  num- 
ber is  always  increased,  from  a  few 
larger  up  to  15  or  20  quite  small  stools 
in  24  hours;  the  odor  may  be  sour 
or  fetid;  the  consistence  is  liquid,  or 
sometimes  frothj^;  the  reaction  is 
generally  acid.  Onlj'  bacteria  native 
to  the  intestinal  canal  are  present, 
although  these  may  be  increased  in 
number. 

In  older  children  the  stools  often 
contain  at  first  undigested  food; 
and  sometimes  the  particular  article 
of  diet  which  has  caused  the  attack 
is  easilj^  recognized.  Later  they  are 
chiefly  watery,  of  a  yellow  or  brown- 
ish color,  and  with  an  offensive  odor. 

Course  and  Prognosis. — Under 
proper  treatment  the  course  is  generally 
short,  and  the  attack  is  over  in  a  few 
days.  It  is  usually,  only  when  the 
disease  has  attacked  infants  during 
hot  weather  that  there  is  danger  of 
the  condition  passing  into  one  of 
gastroenteric  hitoxication  or  ileocolitis. 


o.ro,«,-T„ 

p     -^ 

^~-    fo 

1    » 

9     f 

If 

fJ^ 

o..  «,„..«. 

T.' 

i.      1 

"" 

-180 

M- 

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-160 

-M- 

6fr 

140 

:f 

:_!_: 





130 

62- 

:S--: 

— 



■120 

^56 

-54- 

t 

-MO 

fiO 

•48- 

-100 

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-to* 



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5g 

40 



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u- 

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38 

dO- 

itm* 

-70 

■30 

26 

■60 

26 

24 

J_ 

rt 

Fig.  249. — Acute  Gastro-enteric 
Indigestion  Following  Change  of 
Food. 

Leonard   F.,   aged    10    months.     Suf- 
fered   from    vomiting    for    some    weeks. 
Admitted    to    Children's     Ward    of    the 
Hospital  of  the  University  of  Pennsylvania 
on  Jan.  2,  suffering  from  rickets;   Jan.  6, 
There    is    frequently,    however,    a  ten-     has   been  doing  well,  but  ceased  to  gain, 
dency    for    repeated    attacks   to   occur,     change     of    diet     on     this    date    caused 
Sometimes,      too,    SUSCeptil)le     infants     vomiting,     liquid     greenish     movements 
,.       r  '  ,   .  \      ^  ,        and    fever;    Jan.    11,    fever  ceased;  oon- 

die   from   convulsions,   but  as  a  rule    dition  of  stools  had  improved, 
the  prognosis  is  good. 

Diagnosis. — This  rests  especially  upon  the  diarrhea,  the  shortness 
of  the  course,  and  the  absence  of  toxic  symptoms.  Early  in  the  attack 
the  disease  cannot  with  certainty  be  distinguished  from  acute  gastro- 
enteric intoxication,  which  is.  indeed,  so  fretiuent  a  sequel  unless  great 
care  is  taken. 

Treatment.— The  primary  indications  are  to  stoj)  the  supply  of  food 
and  to  empty  the  bowels.  The  first  is  accomplished  in  infancy  by  ad- 
ministering thin  barley  water  or  even  simply  water  for  24  hours  or  more, 
and  then  employing  all)umen-water  or  broths,  or  a  stronger  barl(>y  de- 

47 


738  THE  DISEASES  OF  CHILDREN 

coction  for  3  or  4  days  more.  It  is  of  the  greatest  importance  that  the 
return  to  milk  be  made  very  gradually,  using  at  first  diluted  skimmed 
milk  or  a  weak  modificaton  of  whole  milk,  and  then  carefully  increasing 
the  strength  of  this. 

Although  the  bowel  may  be  emptied  by  an  enema,  and  should  be  so 
treated  if  the  case  is  seen  early  and  there  is  much  abdominal  distention, 
this  is  not  sufficient,  and  purgation  is  required  in  order  to  empty  the  small 
intestine  as  well  as  the  colon.  Castor  oil  or  calomel  are  the  best  drugs 
if  the  stomach  is  tolerant.  The  dose  of  calomel  is  practically  the  same 
for  any  period  of  fife;  namely  j-g  grain  (0.008)  every  3^^  to  labour  until 
10  doses  are  taken,  followed  by  some  sahne.  For  this  purpose,  or  used 
without  the  calomel,  milk  of  magnesia,  or  citrate  of  magnesia  for  older 
children,  is  very  efficacious.  If  diarrhea  persists  astringents  must  be 
emploj^ed,  especially  bismuth,  perhaps  with  small  doses  of  opium  if 
required;  but  this  treatment  must  not  be  used  as  long  as  fever,  abdominal 
distention,  and  nervous  symptoms  of  any  nature  are  present,  since  these 
are  often  an  indication  that  the  bowel  is  not  yet  emptied  of  the  harmful 
contents  and  that  the  disturbance  of  the  digestion  is  still  maintained,  or 
that  more  serious  inflammation  or  intoxication  is  occurring.  Stimulants 
are  seldom  required,  and  only  if  there  is  much  prostration. 

ACUTE  GASTROENTERIC  INTOXICATION  AND  INFECTION 

(Summer    diarrhea;    Milk    poisoning,    Infective    diarrhea ;* Acute   Gastroenteritis; 
Cholera  Infantum;  Food-intoxication) 

This  most  serious  and  very  common  affection  of  early  life,  especially 
of  infancy,  has  been  described  under  various  names.  As  already  pointed 
out,  there  are  no  sharp  etiological  or  pathological  lines  of  distinction  sepa- 
rating it  from  the  acute  intestinal  indigestion  described  (p.  736) ;  the 
latter  being  only  a  milder  form  of  the  former,  and  the  two  disorders 
shading  into  each  other.  Chnically  the  distinction  rests  upon  the  greater 
severity  of  the  local  symptoms  and  the  constitutional  involvement.  It 
is  still  a  matter  of  dispute  to  what  extent  the  disease  is  chemical  or  bac- 
teriological respectively  in  its  origin. 

Etiology. — The  predisposing  causes  are  various.  The  previous 
presence  of  acute  intestinal  indigestion  is  prominent  here,  and  the  influ- 
ences which  lead  to  this.  Among  them  are  defective  hygiene,  debili- 
tated health,  and  especially  the  character  of  the  food.  The  disease  is 
far  more  common  in  infants  fed  artificially  than  in  those  at  the  breast. 
(See  Mortality,  p.  212.)  The  excessive^  hot  weather  of  summer  time  is 
a  very  important  factor,  its  action  being  partly  through  the  depressing 
effect  upon  the  infant  and  the  consequent  interference  with  the  digest- 
ive functions,  partly  through  the  favoring  of  the  rapid  growth  of  bacteria 
in  the  food  (Fig.  248).  The  number  of  cases  of  diarrhea  is  often,  in- 
deed, in  direct  proportion  to  the  existence  of  extremely  warm  weather. 
Age,  too,  predisposes,  the  disorder  being  far  more  common  in  infancy. 
There  is,  however,  no  inherent  special  tendency  to  it  in  the  "second 
summer,"  other  than  the  fact  that  more  infants  are  artificially  fed  at 
that  period.  Undoubtedly,  too,  conditions  affecting  the  general  health, 
such  as  acute  diseases,  rachitis,  and  even  a  constitutional  debility 
predispose. 

The  exciting  cause  of  the  disease  would  appear  to  be  chiefly  the  influ- 
ence of  toxins.  It  is  probable  that  in  some  instances  these  toxins  are  pro- 
duced by  bacterial  action  upon  the  milk  before  it  is  ingested.     In  accord 


ACUTE  GASTROENTERIC  INTOXICATION  739 

with  this  view  is  the  occurrence  of  the  disorder  after  the  ingestion  of 
impure  milk  which  has  been  sterilized;  the  bacteria  ha\'ing  been  killed 
but  the  toxins  remaining.  In  other  cases  the  bacteria  normallj'  present 
in  the  intestinal  canal  (p.  45)  probably  take  on  increased  multiphca- 
tion  and  virulence,  and  are  the  cause  of  increased  production  of  toxins 
which  act  both  locally  and  by  absorption.  In  others  germs  foreign  to 
the  normal  intestinal  flora  are  found  in  large  numbers,  and  in  still  others 
it  is  probable  that  the  continued  employment  of  unsuitable  food  operates 
chemically  without  the  necessity  of  abnormal  bacterial  action  taking 
place. 

The  microorganisms  which  have  been  oftenest  accused  are  the  strepto- 
coccus enteriditis  (Booker),^  the  bacillus  coli  (Escherich)^  the  bacillis 
pyocyaneus,  bacillus  enteriditis,  bacillus  dysenterise,  bacillus  aerogenes 
capsulatus,  and  the  bacillus  proteus  vulgaris.  It  is  quite  certain  that 
no  one  germ  is  specific,  and  just  what  etiological  relationship  the  bac- 
teria hold  to  the  disease  is  still  uncertain.  The  subject  is  rendered  more 
complicated  by  the  fact  that  even  including  ileocolitis,  which  appears 
to  be  a  definite  bacterial  infection,  there  is  no  one  complex  of  symptoms 
which  alone  is  brought  about  by  a  single  species  of  microorganism,  and, 
conversely,  one  species  is  clearly  capable  of  producing  different  clinical 
manifestations. 

Pathological  Anatomy.- — ^The  changes  are  chiefly  degenerative,  in 
contradistinction  to  ileocolitis  where  injflammatory  lesions  predominate. 
They  may  affect  the  whole  gastrointestinal  tract.  The  stomach  is  usually 
distended  with  gas.  Its  mucous  membrane  is  slightly  thickened,  injected, 
and  of  a  bright-red  color  in  patches,  or  it  may  be  anemic.  Parts  of 
the  rugae  project  more  than  normal  and  these  are  the  regions  oftenest 
reddened.  Minute  hemorrhages  are  sometimes  visible,  and  abundant 
secretion  of  nmcus  may  cover  the  gastric  walls.  A  similar  condition 
obtains  in  both  the  small  and  the  large  intestine,  the  ileum  being  the 
portion  oftenest  most  involved,  showing  marked  congestion  in  some  por- 
tions while  other  areas  may  be  unusually  pale.  The  solitary  follicles 
and  Peyer's  patches  are  abnormally  prominent  and  generally  congested. 
It  is  noteworthy,  however,  how  slight  the  macroscopic  lesions  ma}-  often 
be,  even  when  the  symptoms  have  been  severe. 

Microscopically  there  is  found  a  degeneration  of  the  epithelial  cells 
of  the  mucous  membrane,  varying  in  degree  with  the  intensity  of  the  toxic 
action.  This  is  the  characteristic  lesion  of  the  disease.  In  addition 
severer  cases  exhibit  more  or  less  desquamation  producing  loss  of  the 
epithelium  in  many  places.  There  is,  further,  a  small-celled  infiltration 
of  the  unicous  membrane  including  Peyer's  patches  and  the  solitary 
follicles.  Bacteria  penetrate  the  intestinal  wall  only  in  the  regions  where 
there  has  l)een  loss  of  the  epithelial  lining  (Booker).^  Tiioy  may  even  rc.-icli 
the  lymphatic  glands  and  channels,  the  peritoneum,  or  other  parts  of  the 
l)ody,  and  even  occasionally  give  rise  to  symptoms  of  septicemia.  Some 
of  the  organs  may  at  times  show  the  result  of  the  action  of  the  toxins. 
Thus  the  liver  may  exhibit  fatty  degeneration  of  its  cells;  the  kidneys 
some  degree  of  cellular  d(!generation  in  severe  cases;  the  mesenteric 
glands  are  often  enlarged;  broncliopneumonia  is  not  iiifrcciuciit  and 
occasionally  cerebral  change's  may  occur.     The  pathological   condition 

1  Johns  Il()i)kiiis  Hosp.  [{cp.,  ISiKi,  \I. 

-  Esclicricli  :tii(l  I'fiiiiudlcr,  in  Kollc  !in(l  \\  Msscrinann  HmikII).  d.  pjilliun.  .Mi<r<>- 
org.,  1902,  4;^i;;ilso  17  ("onur.  f.  inn(>r.  Med.,  IS'I'I,  42.").     l^cf.,  (V.orny  and  Keller.  I1I2. 
^  Loc.  cil. 


740  THE  DISEASES  OF  CHILDREN 

shades  gradually  into  the  characteristics  of  ileocolitis;  the  inflammatory 
infiltration  and  ulceration  being  greater  in  the  latter  and  the  colon  being 
the  region  principal!}'  affected. 

Classification. — The  disease  may  affect  either  the  stomach  or  the 
intestines,  or  many  diverse  symptoms  connected  with  other  parts  of  the 
body  may  assume  especial  importance;  but  in  general,  cases  may  be 
divided  into  three  classes  not  sharply  separated:  (1)  The  ordinary  type; 
(2)  acute  milk-poisoning;  (3)  choleriform  diarrhea;  it  being  understood, 
however,  that  these  are  only  somewhat  different  clinical  manifestations 
of  a  single  disorder. 

1.  The  Ordinary  Type. — This  may  develop  either  in  infants  or  in 
older  children.  The  symptoms  vary  according  as  the  stomach  or  the 
intestine  bears  the  brunt  of  the  attack.  In  infancy  the  stomach  is  gen- 
eralh'  involved  to  some  extent  at  least,  the  symptoms  manifesting  them- 
selves gradually  after  some  evidences  of  indigestion;  or  quite  suddenly 
with  fever  of  101°  to  103°F.  (38.3°C.  to  39.4°C.)  or  sometimes  105°  to  106°F. 
(40.6°  to  41.1°C.),  combined  with  colic  and  vomiting.  The  nervous  symp- 
toms are  early  in  appearing.  They  may  consist  only  of  restlessness, 
irritability,  and  fever;  but  not  infrequently  there  is  great  prostration, 
sunken  eyes,  unconsciousness,  or  convulsions,  and  the  child  appears  very 
ill.  There  is  loss  of  appetite;  but  sometimes  great  thirst  causes  liquid 
nourishment  from  a  bottle  to  be  taken  readily.  The  vomiting  may  be 
moderate  and  soon  cease  or  be  even  entirely  absent,  or  it  may  be  severe 
and  very  persistent.  The  vomited  matter  is  at  first  the  food  taken,  and 
later  even  any  water  swallowed,  or  may  consist  of  mucus  or  bile.  Gen- 
erally vomiting  stops  soon  or  becomes  a  minor  symptom.  Diarrhea 
develops,  as  a  rule,  within  24  hours.  The  movements  are  at  first  chiefly 
fecal,  often  with  white  curdy  masses;  but  later  may  become  very  liquid, 
of  a  greenish  or  pale-yellow  color  and  of  an  offensive  odor  and  contain  but 
small  amounts  of  fecal  matter.  A  large  quantity  of  gas  is  often  passed  b}- 
the  rectum.  The  stools  vary  from  2  to  3  to  15  or  20  in  24  hours.  They 
are' very  often  preceded  by  pain  and  expelled  with  force  and  sometimes 
with  moderate  straining,  and  with  more  or  less  mucus;  but  this  condition 
is  not  as  marked  as  in  ileocolitis.  The  development  of  diarrhea  is  often 
attended  by  a  diminution  or  subsidence  of  fever  and  an  improvement  in 
the  nervous  symptoms;  but  if  the  case  continues  and  if  the  stools  are 
large,  wasting  of  the  body  rapidly  takes  place,  the  pulse  is  accelerated  and 
weak,  and  the  prostration  is  unchanged  or  grows  worse.  The  urine  is 
usually  scanty  and  often  contains  albumin,  and  in  severe  cases  casts. 

In  older  children  the  onset  is  oftenest  abrupt,  vomiting  may  occur 
but  is  less  frequent  than  in  infancy,  and  abdominal  pain  is  a  more  promi- 
nent symptom.  The  nervous  symptoms  likewise  are  usually  less  marked 
and  the  temperature  is  not  so  high.  The  stools  are  very  offensive,  litiuid, 
and  usually  of  a  brownish  color. 

Course  and  Prognosis  of  the  Ordinary  Type. — In  the  more  favorable 
cases,  properly  treated,  the  severity  of  the  general  symptoms  is  lessened 
and  the  temperature  falls  when  diarrhea  begins,  and  after  this  has  lasted 
a  week  or  more  the  stools  gradually  grow  less  frequent  and  of  a  l)etter 
character  and  convalescence  is  established.  Not  infrequently,  how- 
ever, the  fever  lessens  but  does  not  disappear,  and  runs  an  irregular 
course,  the  abnormal  stools  persist,  and  the  attack  assumes  a  subacute 
form,  with  difficulty  distinguishable  from  the  later  stages  of  ileocolitis 
undergoing  recovery;  while  sometimes  the  condition  passes  into  an 
actual  ileocolitis.     In  other  severe  cases  the  patient  may  never  recover 


ACUTE  GASTROENTERIC  INTOXICATION  741 

from  the  initial  toxic  stao;e,  and  death  may  occur  in  2  or  3  days,  either 
with  severe  diarrhea  or  with  obstinate  vomiting  or  both.  In  other 
instances  the  fever  is  moderate  at  first,  but  rises  to  hyperpyr^'xia  just 
before  a  fatal  termination.  In  general  it  ma.y  be  said  that  the  severity 
of  the  attack  is  not  necessarily  in  proportion  to  the  frequency  of  the 
diarrheal  stools.  There  is  always  danger  that  at  any  time  mild  instances 
of  the  disease  may  suddenly  assume  a  very  severe  form  and  the  patient 
fail  rapidly.  In  all  cases  in  infancy  there  is  constant  likelihood  of 
relapse  in  spite  of  care,  but  generally  due  to  some  discoverable  error 
in  diet.  The  patient,  who  appears  out  of  danger,  all  symptoms  having 
ceased,  may  then  experience  sudden  recurrence  of  the  disease  in  a  mild 
or  severe  form. 

The  prognosis  is,  on  the  whole,  favorable  in  older  children,  but  in 
infants  always  uncertain,  owing  to  the  various  dangers  which  threaten. 
It  is  worse  in  proportion  to  the  youthful  age  of  the  patient,  the  severity  of 
the  symptoms,  the  existence  of  previous  ill-health,  the  unhygienic  con- 
ditions which  obtain,  and  perhaps  especially  the  character  of  the  weather. 
The  sudden  onset  of  exceedingh'  hot  weather  may  rapidly  carry  off  a 
patient  who  had  been  doing  well.  Among  the  poor  the  disease  is  more 
fatal  than  among  the  well-to-do,  and  in  hospital  practice  the  course 
is  liable  to  be  prolonged  and  the  prognosis  then  becomes  unfavorable 
in  spite  of  every  care.  Breast-fed  children  not  only  develop  the  disease 
much  less  often,  but  offer  a  vastly  better  prognosis. 

2.  Acute  Milk-poisoning  ;  Alimentary  Intoxication. — This 
form  of  the  disease  shades  into  the  variety  just  described.  It  may  occur 
in  infants  previously  well,  but  oftener  it  is  a  later  stage  of  an  intestinal 
indigestion.  It  is  the  "alimentaiy  intoxication,"  the  fourth  form,  of 
Unkelstein's  classification  (p.  698)  which  is  \evy  probably  dependent 
upon  an  acidosis.  The  cause  is  apparently  clearly  a  fault  in  metabolism 
depending  upon  the  nature  of  the  food;  since  in  favorable  cases  symptoms 
cease  when  nourishment  is  withdrawn.  These  symptoms  have  already 
been  described  to  some  extent  (pp.  636,  699).  The  earliest  is  fever, 
either  moderate  or  high;  generally  accompanied  by  a  diarrhea  of 
various  kind  and  degree,  with  rapid  loss  of  weight  and  frequently  with 
vomiting.  In  well-marked  cases  there  are,  further,  great  prostration; 
restlessness;  lassitude;  delirium;  coma  or  convulsions;  sunken  eyes; 
shri\'elled  skin;  pinched  features;  collapse;  painful  muscular  contraction; 
albuminuria  with  casts;  mellituria;  dyspnea  with  deoj)  respiration;  a 
high  (legre(>  of  leucocytosis;  and,  in  some  instances  cough.  Some  cases 
differ  in  that  there  is  no  fever  or  diarrhea.  This  is  particularly  true  of 
marantic  infants.  The  i)riiH'ipal  characteristic  of  the  disease  is  the  great 
predominance  of  the  nervous  and  other  symptoms  of  acidosis  seen  from 
the  beginning;  the  degree  of  vomiting  and  diarrhea  by  no  means  account- 
ing for  the  severity  of  the  condition. 

Course  and  Prognosis  of  Acute  Milk-poisoning. — In  mild  cases,  seen 
early  and  prf)nii)tly  treated,  recovery  luiiy  occur;  but,  as  a  rule,  in  the 
severer  cases  th(>  prognosis  is  most  unfavoral)le.  No  change  for  the  better 
occurs  and  death  takes  phice  in  a  very  few  days. 

3.  CiioLEHiFoHM  DiAHiuiKA.  -This  may  occur  in  infants  and  then  is 
d(\signated  by  th(>  tith'  cholera  iafanlnm.  In  older  children  it  is  called 
cholera  nostras,  constituting  the  complex  of  symptoms  tlescrilied  by  the 
older  writers  under  the  title  of  "cholera  morbus."  Both  are  a  severe 
form  of  acute  gastroenteric  intoxication. 


742  THE  DISEASES  OF  CHILDREN 

Symptoms. — Cholera  infantum  is  by  no  means  a  common  disease, 
and  the  great  majority  of  cases  to  which  the  title  is  appHed  are  incorrectly 
designated.  As  a  rule  the  attack  is  preceded  by  indigestion,  or  by 
acute  gastroenteric  intoxication  of  the  ordinary  type;  after  which  the 
choleriform  symptoms  set  in  with  great  suddenness.  Vomiting  occurs 
and  is  uncontrollable,  or,  if  ceasing  for  a  time,  recurs  promptly  if  any  food 
is  ingested.  The  vomited  matter  is  at  first  the  contents  of  the  stomach 
and  then  merely  a  greenish  liquid.  Simultaneously,  or  a  trifle  later,  diar- 
rhea develops.  At  first  this  is  of  the  character  seen  in  orchnary  cases  of 
acute  gastroenteric  infection,  but  very  soon  becomes  watery,  of  a  greenish 
color,  and  then  almost  colorless,  with  but  little  odor.  The  stools  are  very 
frequent  and  generally  large ;  or  sometimes  small  and  occurring  every  few 
minutes  and  finally  involuntarily,  the  fluids  of  the  body  being  rapidly 
lost  in  this  way.  Extreme  prostration,  loss  of  weight,  sinking  and  filmi- 
ness  of  the  eyes,  shrivehng  of  the  face,  and  pallor  and  wrinkhng  of  the 
skin  develop  with  an  astonishing  rapidity.  The  whole  aspect  of  the  face 
is  completely  changed  in  a  few  hours.  The  temperature  is  usually  ele- 
vated and  hyperpyrexia  is  common  in  fatal  cases.  The  pulse  is  weak  and 
rapid;  the  respiration  often  irregular;  the  urine  is  nearly  or  quite  sup- 
pressed, and  may  be  albuminous;  thirst  is  very  great;  the  abdomen  is 
shrunken;  the  tongue  coated,  or  red  and  dry.  Often  the  body  becomes 
cold  and  cyanotic  as  in  the  algid  stage  of  Asiatic  cholera,  although  the 
rectal  temperature  at  the  time  may  show  an  elevation  of  106°F.  (41.1°C.) 
or  over.  In  other  cases  the  rectal  temperature  is  finally  subnormal. 
Nervous  symptoms  are  marked.  At  first  there  is  usually  irritability 
and  restlessness;  later  there  may  be  a  state  of  apathy  or  stupor,  or  coma 
and  convulsions  may  develop. 

The  cholera  nostras  of  older  children  is  likewise  not  a  common 
condition.  After  some  indiscretion  in  diet  there  develop  very  sud- 
denly severe  and  almost  constant  vomiting,  abdominal  pain,  and  re- 
peated diarrhea.  The  stools  are  colored  or  nearly  colorless,  and  may 
be  extremely  offensive.  The  temperature  is  elevated;  the  cerebral 
symptoms  less  marked  than  in  infants,  but  the  same  wasting  and 
general  appearance  develop. 

Course  and  Prognosis  of  Choleriform  Diarrhea,— The  prognosis  in 
cholera  infantum  is  serious  and  the  majority  of  cases  die.  The  disease 
may  last  not  over  24  hours  or  perhaps  2  to  3  days.  In  some  instances  the 
diarrhea  and  vomiting  continue  until  death  occurs  in  collapse.  In 
others  there  may  be  an  abatement  or  even  a  cessation  of  the  gastro- 
enteric symptoms,  but  nervous  manifestations  with  prostration  may 
persist,  and  death  may  take  place  from  convulsions  or  in  coma.  This  is 
the  condition  described  as  pseudomeningitis  or  hydrencephaloid.  In 
the  case  of  older  children  the  prognosis  is  hkewise  serious  but  not  to  so 
great  a  degree. 

Complications  and  Sequels  of  Acute  Gastroenteric  lntoxica= 
tion. — In  the  ordinary  type  of  the  tlisease,  if  at  all  long  continued, 
complications  may  arise.  Bronchopneumonia  and  otitis  are  common, 
furunculosis  and  multiple  abscesses  may  develop.  Urticaria  and  ery- 
thema are  oftener  seen  in  older  children;  forms  of  stomatitis  are  sometimes 
met  with,  and  renal  involvement  is  not  infrequent.  Sclerema  is  a  compli- 
cation reported  in  cholera  infantum,  but  must  be  rare  in  this  country. 
IleocoHtis  is  a  not  infrequent  sequel.  In  cholera  infantum  and  in  acute 
milk-poisoning  the  course  is  so  rapid  that  there  is  scarcely  opportunity  for 
complications  to  develop. 


ACUTE  GASTROENTERIC  INTOXICATION  743 

Diagnosis. — The  diagnosis  at  the  outset  is  not  readily  made'^from 
acute  intestinal  indigestion,  or  from  vomiting  and  diarrhea  symptomatic 
of  the  onset  of  acute  contagious  fevers.  Acute  intestinal  indigestion  gen- 
erally exhibits  a  lower  temperature,  a  shorter  course  and  much  less  serious 
involvement  of  the  nervous  system.  The  cHnical  differences  are,  how- 
ever, as  stated,  only  those  of  degree.  Often  ileocolitis  cannot  be  readily 
distinguished,  especially  as  it  is  so  frequently  a  sequel  to  gastroenteric 
infection.  It  generally  exhibits  a  greater  amount  of  mucus  in  the  stools, 
which  are  more  numerous  and  smaller,  may  contain  blood,  and  are  passed 
with  pain  and  frequent  straining  efforts;  while  the  temperature  continues 
elevated  instead  of  falling  in  a  few  days.  Only  the  course  of  thetcase 
can  distinguish  the  symptomatic  gastroenteric  manifestations  which  so 
frequently  usher  in  various  acute  febrile  diseases,  and  sometimes  in  the 
intestinal  form  of  grippe  the  diagnosis  may  be  difficult  throughout. 
The  differentiation  from  typhoid  fever  in  infancy  is  at  times  difficult.  In 
most  cases  of  acute  gastrointestinal  intoxication,  however,  the  course  is 
shorter  and  the  fever  falls  in  a  few  days,  and  in  addition  the  test  for  the 
Widal  reaction  will  be  an  aid.  The  nervous  symptoms  of  the  severer 
cases  of  gastroenteric  intoxication  sometimes  suggest  meningitis  at  the 
outset.  Usually  the  prompt  development  of  diarrhea,  uncommon  in 
meningitis,  makes  the  diagnosis  plain.  Cholera  infantum  will  be  recog- 
nized by  the  violent  repeated  vomiting  and  the  serous  discharges;  and  the 
choleriform  diarrhea  of  older  children  could  resemble  meningitis  only  in 
the  vomiting;  its  onset,  too,  being  usually  much  more  sudden.  In  older 
children  acute  poisoning  by  arsenic  or  similarly  acting  drugs  could  produce 
symptoms  suggesting  choleriform  diarrhea. 

Treatment  of  Acute  Gastroenteric  Infection.  Prophylaxis. — 
This  is  of  extreme  importance.  Weaning  must  be  discouraged,  especially 
in  summer  time,  unless  it  has  been  proven  beyond  doubt  that  artificial 
food  is  necessary.  The  longer  the  infant  can  be  successfully  breast-fed 
the  less  is  the  danger  of  gastrointestinal  disturbance.  The  mother's 
nipples  and  the  infant's  mouth  must  be  kept  clean,  and  absolute  regularity 
in  the  hours  of  feeding  followed  (see  p.  85).  In  the  case  of  bottle-fed 
infants  every  precaution  must  be  taken  to  preserve  an  aseptic  condition 
of  the  bottles  and  nipples  and  of  the  food  employed  (see  p.  135).  Great 
care  must  be  taken,  too,  in  starting  an  infant  on  artificial  food,  to  employ 
at  first  very  weak  mixtures  and  to  increase  the  strength  gradually,  feeling 
one's  way  carefully  as  to  the  special  ingredients  of  the  diet  which  should 
be  increased  in  amount,  and  at  once  checking  this  increase  if  signs  of 
indigestion  occur.  It  must  be  remembered  in  this  connection  that  mere 
failure  to  gain  weight  is  not  a  necessary  indication  for  adding  to  the 
strength  of  the  nourishment. 

During  periods  of  unusually  torrid  weather  a  temporary  decided  re- 
duction of  the  strength  and  of  the  amount  of  the  food  and  the  frequency 
of  feeding  is  an  excellent  prophylactic  measure.  The  problem  of  the 
supply  of  proper  food  to  bottle-fed  infants  among  the  poor  in  cities, 
especially  during  the  summer,  is  a  vital  one,  only  to  be  solved  in  the 
charitable  supplying  of  suitably  modified  milk  in  such  a  manner  that 
it  can  be  preserved  from  bacterial  changes  after  it  is  delivered  to  the 
patients.  The  civic  efforts  to  instruct  mothers  in  the  proper  manner  of 
feeding  their  infants,  to  which  so  much  attention  has  been  given  of  recent 
years,  and  which  has  already  borne  good  fruit,  is  also  a  matter  of  the 
greatest  importance.  Even  in  better  social  conditions,  where  the  best 
milk  can  be  obtained,  it  is  advisable  to  pasteurize  during  the  hottest 


744  THE  DISEASES  OF  CHILDREN 

weather,  since,  than  milk,  there  is  no  substance  which  siipphes  a  better 
culture-medium  for  the  growth  of  bacteria.  In  the  case  of  older  children, 
especially  in  summer,  care  must  be  taken  that  no  indigestible  food,  such 
as  unripe  fruit,  is  allowed. 

The  sustaining  of  the  digestive  power  of  the  patient  by  prompt  removal 
from  the  city  during  the  hot  weather  is  a  matter  of  muchimportance.  The 
infants  of  the  poor  should  be  sent  for  the  day  into  the  parks,  to  the  sea- 
shore, or  on  the  river  if  these  are  accessible.  The  infant  should  be  bathed 
every  day,  and  in  verj-  hot  weather,  where  the  child  shows  signs  of  ex- 
haustion, several  short  immersions  in  the  tub  daily  are  sometimes  of 
great  help  in  preserving  the  health.  The  clothes  must  be  carefully 
adapted  to  the  state  of  the  weather.  Chilling  of  the  surface  undoubtedly 
predisposes,  but  even  to  a  greater  extent  does  the  use  of  too  warm  cloth- 
ing in  summer  time.  Constant  supervision  of  the  children  of  the  poor 
by  district  physicians  and  visiting  nurses  is  of  great  value  in  the  preven- 
tion or  early  recognition  of  digestive  disorders. 

1.  Treatment  of  the  Attack.  Ordinary  Type.  Diet. — Dietetic  treat- 
treatment  is  by  far  the  most  important.  This  is  similar  in  nature  to  that 
recommended  for  acute  gastric  or  intestinal  indigestion.  On  the  first 
evidence  of  digestive  disturbance  food  must  be  withdrawn  absolutely. 
This  is  Nature's  own  remedy,  as  shown  by  the  frequent  refusal  of  nourish- 
ment by  infants  and  children  at  this  time.  There  is  no  question  but  that 
many  an  infant  would  be  spared  a  severe  attack  if  no  food  whatever 
were  urged  or  even  permitted  until  appetite  returned.  Water  must  be 
offered  freely,  since  what  may  appear  to  be  appetite  for  food  is  often 
only  thirst.  Infants  at  the  breast  are  best  given  only  water,  thin  barley 
water,  or  strained  broth  for  24  hours,  or  even  longer  if  severe  symptoms 
persist.  After  this  period  nursing  may  be  cavitiously  resumed,  curtailing 
the  duration  of  each  nursing  and  perhaps  alternating  with  barley  water. 
In  the  case  of  bottle-fed  infants  the  same  method  of  treatment  should  be 
followed,  except  that  the  return  to  a  milk-food  must  be  delayed  longer; 
broth,  albumen  water,  or  barley  water  or  other  cereal  decoction  taking 
its  place.  Only  small  amounts  of  nourishment  should  be  given  at  a 
time,  and  less  frequently  than  in  health.  Where  one  kind  of  nourish- 
ment is  refused  and  feeding  seems  advisable,  some  other  may  be  tried 
until  the  child's  fancy  is  satisfied.  It  is  only  in  the  case  of  infants  already 
marantic  that  somewhat  prolonged  starvation  can  do  harm.  Not  until 
after  several  days,  when  symptoms  have  nearly  or  cjuite  disappeared, 
can  a  return  to  milk  be  made,  diluted  skimmed-milk,  buttermilk,  or 
casein  milk  being  often  a  useful  milk  preparation  for  first  use.  Both  fat 
and  sugar  are  liable  to  disagree,  although  in  many  instances  whey  is 
remarkably  useful  in  spite  of  its  sugar-content.  For  infants  past  the 
nursing  period,  and  for  older  children,  the  avoidance  of  milk  is  advisable 
also,  giving  broths  and  gruels  instead  for  a  number  of  days.  If  th*^  con- 
dition persists  the  various  dietetic  methods  recommended  for  chronic 
gastric  and  intestinal  indigestion  may  be  employed.  (See  pp.  725  and  767.) 
After  recovery  at  any  age  the  great  tendency  to  relapse  and  recurrence, 
especially  in  summer,  make  t  imperative  to  use  much  caution  in  return- 
ing to  the  ordinary  food.  Indeed,  in  summer-weather  the  diet  may  need 
curtailing  until  the  hot  season  is  past. 

Hygiene. — In  addition  to  care  in  the diet,  the  hygiene  of  the  patient 
must  be  considered.  The  measures  suggested  for  prophylaxis  apply  here 
as  well.  The  child  should  be  kept  at  rest  in  bed  or  in  its  coach,  but  it  is 
a  mistaken  idea  that  patients  with  the  acute  symptoms  of  the  disease 


ACUTE  GASTROENTERIC  INTOXICATION  745 

must  be  necessarily  confined  to  the  house,  although  under  some  circum- 
stances it  maj^  be  better  that  they  shall  be  during  the  excessive  heat  of 
mid-day.  Abundant  fresh  air  is  needed  with  light  clothing  if  the  weather 
is  hot,  but,  on  the  other  hand,  chilhng  of  the  surface  of  the  body  by  cool 
draughts  is  to  be  avoided.  During  hot  weather,  or  if  there  is  much  fever, 
the  use  of  baths  is  of  value.  For  this  purpose  the  warm  tub  bath  of 
100°F.  (37.8°C.),  given  several  times  daily,  is  often  better  borne  and  more 
efficacious  than  sponging  with  cooler  water.  Very  important  often  is  a 
change  of  climate  to  a  cooler  and  more  bracing  region. 

Medicinal  and  Local  Treatment. — This  is  entirely  symptomatic.  If 
the  case  is  seen  early  or  if  feeding  has  been  persisted  in  by  the  mother,  a 
purgative  should  be  administered.  Castor  oil  is  excellent,  but  only  if 
vomiting  has  ceased.  Calomel  with  soda  is  a  serviceable  remedy,  giving 
l^in  grain  (0.0065)  of  the  former,  with  1  grain  (0.065)  of  the  latter,  hourly 
or  half  hourly,  to  a  child  of  6  months  until  5  to  10  doses  have  been  taken. 
Milk  of  magnesia  is  also  an  excellent  preparation,  alone  or  following  the 
calomel.  For  older  children  the  solution  of  citrate  of  magnesia,  2  to -4 
ounces  (59  to  118)  is  useful.  In  addition  to  the  purgative,  irrigation  of  the 
colon  with  a  normal  salt  solution  is  advisable  in  nearly  every  case  in 
order  to  empty  this  part  of  the  intestine  promptly.  Later  it  may  be 
done  once  "or  twice  a  day  w^hile  active  symptoms  last.  It  should  not  be 
continued  too  long,  since  the  procedure  itself  is  sometimes  a  source  of 
moderate  intestinal  irritation.  Cool  irrigation,  too,  is  often  a  useful 
means  of  reducing  fever,  if  this  is  unduly  high.  The  employment  of  the 
tub  bath  for  the  reduction  of  fever  has  already  been  alluded  to.  When 
vomiting  is  persistent  and  there  is  reason  to  believe  that  the  stomach  still 
contains  undigested  food,  lavage  with  a  1  per  cent,  solution  of  bicarbonate 
of  soda  is  of  great  service.  In  place  of  this  the  exhibition  hourly  of  ^2 
dram  (2)  each  of  liquor  calcis  and  aqua  cinnamomi  is  an  excellent  pro- 
cedure, somewhat  larger  doses  being  given  to  older  children.  In  some 
cases  of  vomiting  bismuth  with  bicarbonate  of  soda  is  of  value.  Should 
diarrhea  persist  to  a  moderate  degree,  not  too  great  haste  can  be  per- 
mitted in  efforts  to  check  it.  This  is  especially  true  if  fever  or  nervous 
symptoms  continue;  since  these  may  be  a  sign  that  there  are  still  irritating 
substances  present.  Under  such  circumstances  the  administration  of 
castor  oil,  magnesia,  Rochelle  salts,  or  other  purgative  once  or  twice 
daily  for  a  few  days  is  often  of  value. 

After  the  general  symptoms  have  disappeared  a  continuance  of  dira- 
rhea  may  call  for  direct  treatment.  Bismuth  is  now  useful,  5  or  10  grains, 
(0.32  or  0.65)  being  given  every  2  hours  to  a  child  of  a  year  or  less, 
preferably  either  the  subcarbonate  or  subgallate  being  employed.  The 
salicylate  of  bismuth  is  often  prescribed  on  the  ground  that  its  antiseptic 
power  is  greater.  There  seems,  however,  little  reason  to  believe  that 
the  small  amount  of  antiseptic  contained  could  have  any  real.influence  on 
the  relatively  very  large  mass  of  the  intestinal  contents.  Astringent 
remedies  such  as  tannalbin  and  tannigen,  or  the  older  jtreparations  con- 
taining tannic  acid,  are  to  be  reserved  for  cases  which  pass  into  a  subacute 
stage,  the  result  of  the  development  of  ileocolitis  as  a  sequel.  Opium  is 
an  invaluable  remedy  in  some  cases  but  a  dangerous  one  in  others.  To 
avoid  it  entirely  is  as  much  an  error  as  to  use  it  improperly.  It  nmst  not 
be  exhibited  in  the  early  stages  when  vomiting  and  nervous  symptoms 
are  present,  or  where  there  is  reason  to  believe  that  the  locking  up  of  the 
bowels  would  be  haiinful.  Later,  however,  it  often  happens  that  there 
is  a  too  great  outpouring  of  liquid  into  the  intestinal  canal  and  too  ener- 


746  THE  DISEASES  OF  CHILDREN 

getic  a  peristalsis,  as  a  result  of  which  food  and  liquid  are  hurried  on  and 
out  of  the  intestine,  with  consequent  prostration  and  emaciation.  In 
such  instances  opium  is  more  serviceable  than  any  other  remedy.  The 
dose  to  be  employed  varies  with  the  case  and  the  effects  produced.  (See 
Table  of  Doses,  p.  000.)  It  is  also  useful  to  allay  the  severe  cohc  which  is 
sometimes  a  symptom.  On  the  other  hand,  given  inopportunely,  it  may 
increase  gaseous  distention  by  checking  peristalsis  too  greatly.  CoUc  and 
distention  may,  'ndeed,  often  be  relieved  by  the  application  of  spice 
poultices  or  of  stupes,  or  by  the  employment  of  a  rectal  tube  or  a  small 
enema. 

As  the  disease  in  the  severer  cases  is  a  rapidly  debihtating  one,  meas- 
ures must  be  taken  to  sustain  the  strength  of  the  patient.  Hot  mustard 
baths  or  packs  will  be  of  service  if  collapse  is  threatening.  Alcohohc 
stimulation  may  be  needed  throughout  in  the  severer  cases.  The  amount 
to  be  given  and  the  frequency  of  dosage  varies  with  the  age  and  the  de- 
mands of  the  case,  from  }i  to  }i  dram  (1  to  2)  of  whiskey  or  brandy 
being  administered  every  2  or  3  hours,  for  a  short  period  only,  to  a  child 
of  from  1  to  2  years  of  age.  Digitahs,  caffeine  or  camphor  may  be  re- 
quired at  times,  the  last  two  often  preferably  given  hypodermically. 
When  there  has  been  great  loss  of  fluid  from  the  system,  and  when 
vomiting  precludes  the  administration  of  sufficient  hquid  by  the  mouth, 
enteroclysis  is  often  of  value,  a  warm  normal  salt  solution  being  given 
slowly.  Only  in  the  worst  cases  is  hypodermoclysis  necessary.  The 
procedure  is  painful  and  tedious  and  sometimes  an  intraperitoneal  in- 
jection is  to  be  preferred. 

2.  Acute  Milk  Poisoning. — The  first  indication  for  treatment  is  the 
absolute  withdrawal  of  all  food.  Nothing  but  water  should  be  adminis- 
tered, given  either  by  the  stomach,  if  it  can  be  retained,  or  in  the  form  of 
normal  salt  or  a  1  per  cent,  bicarbonate  of  soda,  solution  by  enteroclysis. 
As  the  intoxication  is  dependent  upon  an  acidosis,  full  doses  of  alkalies 
are  needed  when  the  symptoms  are  decided;  given  either  by  the  mouth, 
rectum,  hypodermically,  or  intravenously.  (See  Acidosis,  p.  635.) 
Inasmuch  as  actual  symptoms  of  acidosis  in  this  disease  are  hable  to 
terminate  fatally,  it  is  well  to  anticipate  this  by  giving  from  the  begin- 
ning sufficient  soda  to  keep  the  urine  alkaline.  Hypodermoclysis  or 
intraperitoneal  injection  with  normal  saline  solution  may  be  needed 
in  some  instances.  Return  to  food  must  be  made  very  cautiously. 
Other  treatment  is  symptomatic  and  similar  to  that  recommended  for 
cases  of  the  ordinary  type. 

3.  Choleriform  Diarrhea. — The  treatment  of  this  form  of  acute 
gastroenteric  intoxication,  either  in  infants  or  in  older  children,  is  neces- 
sarily modified  by  the  pecuhar  character  of  the  symptoms,  the  extremely 
rapid  course  of  the  case,  the  frequent  persistence  of  uncontrollable 
vomiting,  the  great  loss  of  Hquid  from  the  system,  and  the  profound  pros- 
tration. Lavage  of  the  stomach  and  intestine  should  be  used  at  once, 
cathartics  being  too  slow  in  their  action  and  being  hable  to  be  rejected 
by  the  stomach.  Morphine  hypodermically,  in  doses  of  >foo  grain 
(0.0006)  to  a  child  of  1  year,  repeated  in  2  hours  if  needed,  is  the  sheet- 
anchor,  except  in  those  cases  where  vomiting  and  diarrhea  have  abated 
but  stupor  and  other  cerebral  symptoms  persist.  In  these  alkaline 
treatment  is  indicated.  Alcohohc  stimulants  should  be  administered 
freely  and  frequently  by  the  mouth  if  vomiting  permits  of  this.  Cam- 
phorated oil  (1:10)  and  suitable  preparations  of  digitalis,  strophanthus, 
and  caffeine  given  hypodermically,  are  of  service  to  combat  the  cardiac 


ACUTE  ILEOCOLITIS  747 

weakness.  The  excessively  high  temperature  may  be  modified  by  cool 
baths;  or  when  the  surface  of  the  body  is  in  the  algid  state  but  the  internal 
temperature  high,  by  colonic  lavage  with  cold  water.  In  some  cases 
cold  compresses  frequently  changed  may  be  applied  to  the  head  and  body 
while  a  hot- water  bag  is  kept  at  the  feet;  and  in  the  algid  stage  hot  baths 
(105°F.)  (40.6°C.)  with  or  without  mustard,  or  a  strong  hot  mustard  pack 
is  of  value.  Food  must  be  even  more  strictly  avoided,  if  possible,  than  in 
the  ordinal}^  type  of  gastrointestinal  intoxication.  It  is  especially  in  the 
choleriform  type  of  the  disease  that  hypodermoclysis  or  intraperitoneal 
injection  should  be  tried,  since  liquid  given  by  enteroclysis  will  not  be 
retained.  After  the  more  acute  symptoms  have  subsided  the  treatment 
is  that  described  for  the  milder  form  of  the  disorder. 

ACUTE  ILEOCOLITIS 
(Enterocolitis;  Follicular  Enteritis;  Dysentery;  Inflammatory  Diarrhea) 

Considerable  confusion  has  arisen  in  the  description  and  classification 
of  forms  of  this  affection.  The  title  has  been  used  contradictorily  to 
describe,  on  the  one  hand,  a  class  of  cases  which  may  exhibit  identical 
clinical  symptoms;  yet  with  entire  variance  in  their  etiology  and  patho- 
logical anatomy;  and,  on  the  other  hand,  those  which  may  be  similar 
etiologicall}^  or  present  similar  lesions  and  yet  be  quite  different  in  clinical 
characteristics.  Some  of  the  specific  germs,  for  instance,  may  be  found  to 
be  the  apparent  cause  in  cases  in  which  the  symptoms  do  not  differ  from 
those  present  when  no  such  germs  are  discoverable.  There  is  also  no 
sharp  boundary-line  between  this  disease  and  acute  gastroenteric  intoxica- 
tion, the  lesions  seen  in  this  latter  being  those  occurring  in  the  first  stage  of 
the  former;  while  clinically  the  subacute  cases  of  intoxication  are  not 
to  be  distinguished  from  the  milder  instances  of  ileocolitis.  The  term 
ileocolitis  properly  designates  a  group  of  cases  in  all  of  which  the  element  of 
inflammation  is  predominatingly  present. 

Etiology.- — Numerous  predisposing  factors  are  of  importance.  Children 
under  2  years  of  age  are  especially  liable  to  suffer  from  the  malady,  but  it'is 
by  no  means  confined  to  this  period.  Acute  gastroenteric  infection  fre- 
quently has  ileocolitis  following  it,  and  the  disease  may  readily  develop  in 
atrophic  children  the  subject  of  chronic  intestinal  indigestion.  It  is,  too, 
a  sequel  at  times  in  older  children  to  some  of  the  acute  febrile  diseases, 
such  as  measles,  typhoid  fever,  pneumonia  and  diphtheria.  It  may, 
however,  readily,  and  perhaps  oftenest,  occur  as  an  acute  primary  disease 
not  preceded  by  any  digestive  or  other  disorder. 

Summer  time  witnesses  the  majority  of  cases,  dependent  not  only  upon 
the  direct  influence  of  hot  weather  on  the  system,  but  upon  the  ready  con- 
tamination of  the  food  by  microorganisms  at  this  season.  Lack  of 
satisfactory  hygiene  of  any  sort  predisposes  to  the  disease.  Consequently, 
as  in  the  case  of  other  digestive  disorders  in  infancy,  it  occurs  oftenest  in 
crowded  districts  in  cities,  and  even  in  well-regulated  institutions  where 
many  infants  are  maintained.  Epidemic  infiuence  is  very  positive. 
This  is  especially  true  of  tropical  countries,  hut  there  may  he  local  out- 
breaks in  temperate  I'cgions.  It  is  oftenest,  however,  seen  sporadically. 
Whether  it  is  contagious  from  one  child  to  another,  or  whether  several 
children  ill  together  may  have  been  infected  from  some  outside  source 
is  not  yet  definitely  known,  but  the  latter  seems  more  probable. 

Ileocolitis  is,  however,  a  distinctly  infectious  disease  and  the  exciting 
cause  is  .a  germ  of  some  sort.     In  tropical  dj-sentery  this  maj'  be  the 


748  THE  DISEASES  OF  CHILDREN 

ameba  coli,  so  nainod  by  Losch,^  and  studied  especially  by  Kartulis.- 
This  microorganism  is  only  occasionally  met  with  in  temperate  climates: 
and  this  is  especially  true  of  children.  In  over  3000  children  seen  by 
DeBu3's,^  only  4  had  amebic  dysenter}'.  Several  different  species  of 
bacteria  appear  to  be  able  to  produce  the  disorder,  among  them  being  the 
colon-bacillus,  a  variety  of  streptococcus,  and  the  bacillus  pyocyaneus; 
but  the  germ  which  seems  to  be  perhaps  oftenest  the  cause  is  the  dysentery- 
bacillus.  This  was  first  descril^ed  by  Shiga'*  in  1898;  and  shortly  after- 
ward, in  1900,  Flexner^  reported  the  discovery  of  another  strain,  differing 
from  the  Shiga-type  in  that  it  produced  in  culture  an  acid  reaction.  The 
presence  of  this  variet}^  in  ileocolitis,  as  well  as  in  other  diarrheal  condi- 
tions in  children,  was  observed  by  Duval  and  Bassett*^  in  1902.  Different 
strains  of  this  germ  have  been  described.  The  original  Shiga,  or  alkaline, 
type,  is  uncommon  in  infants  in  this  country,  and  much  the  more  numerous 
cases  are  associated  with  the  acid  type  of  the  germ,  the  Flexner  variety, 
occurring  alone  or  sometimes  accompanied  by  other  strains,  as,  for  in- 
stance, that  of  Hiss  and  Russell.'^  In  the  Collective  Investigation  of  the 
Rockefeller  Institute^  in  1904,  412  infants  with  diarrheal  disease  were 
studied,  and  the  dysentery  bacillus  found  in  279;  i.e.  63.2  per  cent.  Of 
these  only  29  cases  showed  the  presence  of  the  bacillus  of  the  Shiga  type. 

That  the  dysentery'  bacilli  are  in  realit}^  the  cause  of  many  cases  of 
diarrheal  disease  in  children  would  seem  to  be  indicated  by  the  fact  that 
an  agglutinative  reaction  develops  with  the  blood  taken  from  the  patient. 

It  is  important  to  remember,  however,  that  not  only  is  it  not  proven 
that  the  dysentery  bacillus  is  the  sole  cause  of  ileocolitis  in  children,  but 
it  is  certain  that  these  germs  may  be  present  in  other  diarrheal  conditions, 
and  even  very  exceptionally  in  the  stools  of  normal  infants.  In  some  cases 
of  ileocolitis  an  agglutinative  reaction  has  been  found  with  the  strepto- 
coccus (Jehle).^  The  number  of  bacteria  present  in  the  stools  is  generally 
comparativeh'  small,  but  to  this  there  are  exceptions.  The  mode  of  en- 
trance into  the  body  is  unknown.  The  germs  are  capable  of  living  but 
a  short  time  outside  of  the  body,  but  probably  may  continue  to  exist  and 
to  propagate  themselves  in  the  intestine  for  long  periods  after  the  disease 
itself  is  over. 

Pathological  Anatomy.^ — The  lesions  vary  greatly  in  situation, 
kind,  and  intensity,  dependent  to  a  large  extent  upon  the  duration  and 
severity  of  the  attack.  The  basic  character  of  the  disease  is  inflammation, 
this  distinguishing  it  from  the  diarrheal  disorders  already  described.  As 
regards  situation  the  large  intestine  is  the  most  frequent  seat,  the  lower 
part  of  the  ileum  being  much  less  affected  and  with  more  scattered  and 
superficial  lesions;  but  even  where  most  abundantly  developed  the  lesions 
are  not  uniformly  distributed,  parts  of  the  intestine  being  greath'  involved 
and  the  neighboring  parts  to  a  much  less  extent  if  at  all.  The  degree  of 
change  produced  varies  with  the  case;  and,  based  upon  the  post-mortem 
lesions,  the  disease  has  been  divided  into  different  types.  In  the  acute 
catarrhal  form  the  mucous  membrane  is  congested  and  swollen,  often 

1  Virchow's  Archiv.,  1875,  LXV,  196. 

2  Centralbl.  f.  Bakt.,  1891,  IX,  365. 

3  Journ.  Amer.  Med.  Assoc,  1914,  LXIII,  1806. 

*  Centralbl.  f.  Bakt.,  1898,  XXIII,  599. 

5  Johns  Hopkins  Hosp.  Bullet.,  1900,  XL,  231. 

«  American  Med.,  1902,  IV,  417. 

7  Medical  New.s,  1903.  LXXXII,  289. 

*  Bact.  and  Clin.  Studies  of  the  Diarrheal  Diseases  of  Infancy,  1904,  124. 
«  Jahrb.  f.  Kinderh.,  1907,  LXV,  40. 


ACUTE  ILEOCOLITIS  749 

covered  with  mucus,  and  the  epithehum  loosened  in  places.  Small 
hemorrhages,  usually  scattered  or  in  streaks,  are  seen  on  the  surface  of  the 
mucous  membrane  especially  upon  the  projecting  portion  of  the  folds, 
and  superficial  erosions  may  be  found;  and  in  severe  cases  these  shallow 
ulcerations  may  be  extensive,  and  the  whole  intestinal  wall  may  appear 
much  thickened.  Both  the  solitary  and  the  agminated  folhcles  are 
generally  swollen  and  the  vilh  are  elongated  and  prominent.  The  change 
in  the  agminated  follicles  may  closely  resemble  the  appearance  in  typhoid 
fever.  Microscopically  there  is  found  an  infiltration  of  small  cells  and  of 
very  numerous  bacteria  of  different  kinds  in  the  mucous  layer,  penetrat- 
ing even  to  the  muscular  layer  in  severe  and  long-continued  cases.  The 
h'mph-follicles  are  infiltrated.  In  cases  which  recover  the  lesions  dis- 
appear entireh'. 

If  the  diseased  process  has  advanced  further,  follicular  ileocolitis 
is  also  found.  There  is  here  a  more  or  less  deep  ulceration  in  the  solitary 
follicles.  These  ulcers  are  at  first  very  minute,  but  by  fusion  with  each 
other  and  extension  into  the  adjacent  mucous  tissue  they  may  produce 
lesions  of  considerable  size  with  overhanging  walls.  There  is  a  moderate 
infiltration  of  the  submucous  layer,  and  in  severe  cases  the  muscular 
la3'er  is  much  thickened  and  infiltrated,  and  the  ulceration  extends 
into   it.     Cases   which   recover   do  so  with  cicatrization  of  the  ulcers. 

In  the  most  severe  form  of  the  disease  a  membranous  ileocolitis 
develops.  In  this  condition  there  are  regions  in  which  the  entire  thick- 
ness of  the  intestinal  wall  becomes  much  swollen  and  stiff,  with  an 
obliteration  of  the  usual  folds,  resulting  from  the  presence  of  fibrinous 
exudate  and  infiltration  by  round  cells.  The  surface  is  rough  and 
has  not  the  ordinary  appearance  of  mucous  membrane,  and  the  various 
structures  constituting  it  are  not  readily  distinguishable  from  each  other. 
In  other  regions  where  the  membranous  deposit  has  become  detached, 
deep  ulceration  may  be  seen. 

In  general,  acute  catarrhal  inflammation  is  found  in  the  milder  cases 
of  short  duration;  folhcular  inflammation  does  not  usually  develop  until 
in  the  2d  week;  membranous  inflammation  is  usually  attended  by  severe 
SA^mptoms,  and  may  occur  even  comparatively  early  in  the  disease.  But 
there  is  no  certain  relationship  in  ileocolitis  between  the  severity  of  the 
symptoms  and  that  of  the  lesions.  Cases  with  extensive  ulceration,  for 
instance,  may  sometimes  exhibit  but  moderate  fever  and  little  or  no  blood 
in  the  evacuations,  while  catarrhal  inflannnation  may  perhaps  be  attended 
by  bloody  nuicous  stools,  and  the  case  may  continue  for  some  weeks  and 
end  fatally  without  any  follicular  ulceration  having  developed. 

Lesions  of  other  regions  are  often  associated  with  those  of  the  intestine. 
Bronchopneumonia  is  not  infrequent  and  swelling  of  the  mesenteric 
glantls  may  l)e  found.  Degenerative  changes  in  the  kidneys  are  often 
seen  and  occasionally  true  inflannnatory  alterations  as  well.  J"]nlarge- 
ment  of  tlie  spk^en  may  occur,  with  degenerative  changes  in  it  and  in  tlie 
liver  and  othci-  organs. 

Symptoms.- — For  reasons  already  pointed  out  a  division  of  the 
disease  into  clinical  types  based  upon  pathological  and  bacteriological 
findings  is  possible  only  to  a  limited  extent,  and  the  symptoms  vary 
greatly.  In  what  might  be  called  an  average  case  there  may  have  been 
an  earlier  simple  diarrhea  or  gastroenteric  intoxication,  which  gradually 
merged  into  or  suddenly  developed  a  condition  of  ileocolitis;  or  the 
disease  may  start  abi'uptly  as  a  primary  affect  ion,  pei'haps  following  an 
indiscretion  in  diet,  with  practically  no  protlromes.     The  onset  cannot  be 


750 


THE  DISEASES  OF  CHILDREN 


distinguished  with  certainty  from  that  of  other  acute  intestinal  disturb- 
ances. In  the  more  acute  cases  there  is  fever  of  from  103°  to  104°F. 
(39.4°  to  40°C.),  often  vomiting,  abdominal  pain,  and  diarrheal  movements 
containing  undigested  food.  Very  promptly  the  stools  become  very 
frequent,  small,  are  passed  with  straining  efforts,  and  exhibit  mucus  either 
transparent  or  green  in  color,  pus,  fecal  matter,  and  more  or  less  blood. 
The  abdomen  becomes  moderately  distended  and  somewhat  tender; 
the  urine  is  scanty  and  may  contain  albumin.     There  is  loss  of  appetite. 


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Fig.  250. 


Fig.  251. 


Fig.  250. — Acute  Ileocolitis  of  Moderate  Severity. 
Mollie  G.,  aged  7  months.     Bottle  fed.     Apr.  27,  been  ill  1 1  days  with  mucus,  blood  and 
pus  in  the  movements,  very  frequent,  with  straining,  fever,  prolapse  of  the  rectum.      Con- 
dition now  apparently  improving  slowly.     Temperature  uncharacteristic. 

Fig.  251. — Acute  Ileocolitis. 
Arcetso  P.,  aged  6  months.     Illness  began  with  fever,  vomiting  and  diarrhea,  with 
green,  mucous  stools,  a  week  before  admission  to  the  Children's  Hospital  of  Philadelphia, 
Jan.  28.     Child  weak,  looking  ill,  cyanotic,  having  5  to  8  green,  mucous  stools  in  the  24 
hours,  with  a  little  blood.     Death  on  the  31st.     Temperature  uncharacteristic. 

coated  tongue,  thirst,  decided  prostration  and  rapid  loss  of  weight.  The 
appearance  is  that  of  an  ill  child.  The  tenesmus  is  not  constant  and  the 
abdominal  pain  is  colicky  in  nature;  both  symptoms  developing  or 
increasing  at  the  time  of  eva'iuation  of  the  bowels.  Prolapse  of  the  rec- 
tum is  not  uncommon. 

In  the  severer  cases  evacuations  may  be  accompanied  by  great  tenes- 
mus and  colicky  pain,  may  occur  every  hour  or  even  much  more  fre- 
quently, and  may  contain  blood-tinged  mucus  only,  with  little  or  no 
fecal  matter.  The  tongue  is  dry;  sordes  appears  on  the  lips  and  teeth; 
there  is  great  restlessness  or  apathy,  prostration,  sinking  of  the  eyes, 
stupor,  and  sometimes  dehrium  or  convulsions.     In  milder  cases  char- 


ACUTE  ILEOCOLITIS  751 

acterized  by  slower  onset  the  stools  contain  a  considerable  amount  of 
undigested  food  in  addition  to  mucus,  the  straining  and  abdominal  pain 
are  less  marked,  and  other  constitutional  symptoms  are  but  little  devel- 
oped. Sometimes  the  odor  of  the  stools  is  very  offensive,  but  this  is  less 
apt  to  be  the  case  when  mucus  is  their  chief  constituent. 

The  temperature  in  ileocolitis  is  very  variable.  It  is  liable  to  rise 
rapidly  in  the  primary  and  the  severer  cases  and  continue  high;  or  to 
become  less  elevated  than  at  the  onset  and  more  irregular  in  the  milder 
cases;  but  this  is  open  to  numerous  exceptions  (Figs.  250  and  2,51). 

Course  and  Prognosis. — The  duration  and  development  of  symp- 
toms varies  with  the  intensity  of  the  attack.  In  very  severe  cases  the 
bloody,  mucous  character  of  the  stools  continues  unaltered,  their  fre- 
quency undiminished,  fever  remains  high,  prostration  and  loss  of  weight 
increase  rapidly,  and  death  takes  place  in  from  a  few  days  to  1  or  2 
weeks.  In  other  severe  cases  the  toxic  cerebral  symptoms  occupy  the 
most  prominent  position,  or  are  combined  with  intestinal  manifestations; 
there  being  vomiting,  delirium,  unconsciousness,  prostration,  and  con- 
vulsions. Such  cases  may  exhibit  few  symptoms  considered  character- 
istic of  dysentery.  In  cases  of  catarrhal  ileocolitis  of  average  severity 
the  stools,  which  were  at  first  almost  entirely  of  glairy  mucus  with  blood, 
exhibit  more  or  less  increase  of  fecal  matter  after  2  or  3  days,  are  nearly 
odorless  or  very  offensive,  and  become  more  fluid  and  greenish  or 
brownish,  while  blood  nearly  or  quite  disappears,  although  abundant 
mucus  is  still  present.  The  high  temperature  of  the  onset  becomes  lower 
and  more  irregular,  and  decided  loss  of  flesh  and  strength  continue  and 
is  sometimes  very  great.  Then  after  1  or  2  weeks  in  favorable  cases  im- 
provement begins,  pain  and  tenesmus  lessen,  the  stools  grow  decidedly 
less  in  number  and  are  more  fecal  and  with  less  mucus,  the  temperature 
diminishes,  and  strength  increases.  Convalescence  is,  however,  slow, 
and  it  may  be  4  to  6  weeks  before  mucus  has  disappeared  and  recover}' 
is  complete.  Relapses  are  meantime  very  prone  to  occur.  These  may 
develop  after  convalescence  seems  established,  or  there  may  be  a  return  of 
severe  symptoms,  with  blood  and  increase  of  mucus  at  various  times 
during  the  course  of  the  attack.  Should  the  disease  prove  fatal  the 
symptoms  persist  or  increase  in  severity,  prostration  grows  more  marked, 
the  appetite  is  lost,  the  tongue  dry,  the  evacuations  continue  to  exhibit 
mucus  and  blood,  there  may  be  occasional  vomiting,  delirium  or  con- 
vulsions may  appear,  and  death  occurs  after  4  to  6  weeks  from  exhaustion 
or  from  some  intercurrent  condition,  especially'  bronchopneumonia. 
In  all  the  cases  lasting  several  weeks  it  is  probable  that  the  disease  has 
reached  the  stage  of  ulceration.  Such  ulceration  always  renders  the 
prognosis  more  unfavorable. 

In  the  mild  catarrhal  cases  the  fever  is  never  high,  the  stools  not 
very  numerous  and  unaccompanied  by  much  pain  or  straining,  there  is 
little  prostration,  and  recovery  may  take  place  in  from  10  days  to  2  or 
3  weeks. 

In  the  cases  of  follicular  ileocolitis  the  condition  may  follow  the 
acute  catarrhal  form,  f)r  very  frequently  be  a  sequel  to  an  acute  gastro- 
enteric intoxication,  the  symptoms  of  the  latter  merging  gradually  into 
those  of  the  former,  and  the  case  being  of  a  rather  subacute  typo  from 
the  beginning.  Whether  or  not  the  on.set  in  this  form  is  sudden,  the 
temperature  soon  grows  irregular  and  .seldom  liigh;  the  evacuations 
contain  both  mucus  and  fecal  matter,  little  if  any  lilood,  are  not  very 
numerous,  and  are  passed  with  no  excessive  straining;  marked  nervous 


752  THE  DISEASES  OF  CHILDREN 

disturbances  are  absent;  prostration  is  not  great  at  first;  emaciation  is 
progressive  and  constant  and  finally  becomes  extreme,  and  death  usually 
results  in  3  or  4  weeks  or  longer,  with  the  symptoms  of  advanced  mal- 
nutrition. Improvement  in  such  cases  is  an  indication  that  the  fol- 
licular ulceration  has  not  become  extensive.  Recovery  is  always  very 
tedious  and  relapses  very  frequent.  These  may  be  brought  on  by  any 
indiscretion  in  diet,  chilling  of  the  body,  or  any  departure  from  careful 
hygiene. 

In  general  it  may  be  said  that  the  prognosis  of  ileocolitis  is  much 
graver  if  ulceration  has  developed,  but  that  the  determining  of  the  ex- 
istence of  this  condition  usually  cannot  be  made  with  certainty,  the 
presence  of  blood  generally  depending  upon  congestion  rather  than  ulcera- 
tion. If  the  disease  has  lasted  only  a  week  or  less  and  improvement  in 
the  evacuations  then  begins,  it  is  likely  that  there  is  no  ulceration. 
If  there  is  no  improvement  in  3  or  4  Aveeks  ulceration  is  very  probably 
present.  Between  these  two  there  is  a  middle  ground  where  the  presence 
of  ulceration  is  only  conjectural.  The  prognosis  is  also  influenced  by 
the  age,  being  worst  in  infancy;  while  any  debilitating  disease  or  im- 
paired state  of  health  is  also  unfavorable.  The  primary  cases  give  a 
better  prognosis  than  the  secondary  ones.  The  season  of  the  year  is  of 
great  importance,  hot  summer  weather  making  recovery  much  more 
difficult  and  relapse  especially  likely  to  occur.  Any  unfavorable  hygienic 
surroundings  increase  the  danger.  Hence  in  cities  and  among  the  poor 
the  disease  is  more  dangerous,  as  it  is  also  in  hospitals  and  other  insti- 
tutions in  spite  of  every  effort  for  the  maintenance  of  proper  hygiene. 
The  prognosis  of  ileocolitis  is  always  serious  and  uncertain,  and  the 
death-rate  is  high. 

Complications  and  Sequels. — Bronchopneumonia  is  a  frequent  and 
serious  complication,  appearing  generally  late  in  the  course  of  the  case. 
Thrush  or  other  forms  of  stomatitis  may  develop.  Sepsis  is  a  frequent 
and  early  cause  of  death  in  severe  cases.  Degenerative  lesions  of  the 
kidneys  are  common.  Purulent  otitis,  or  furunculosis  and  other  cuta- 
neous suppurative  conditions,  may  occur.  The  most  important  sequel 
not  infrequently  following  is  a  chronic  ileocolitis.  In  other  cases  a 
persistent  malnutrition  may  remain  for  months  after  the  disease  itself 
is  over.     Obstinate  constipation  is  a  not  uncommon  sequel. 

Diagnosis. — The  principal  diagnostic  symptoms  of  the  disease  are 
the  tenesmus,  abdominal  pain  and  tenderness,  fever,  and  frequent,  small 
stools  containing  mucus  and  more  or  less  blood.  Yet  the  symptoms  vary 
to  such  an  extent  that  the  diagnosis  is  often  not  easy.  When  preceded 
by  acute  gastroenteric  infection  it  is  often  impossible  to  determine  just 
when  the  actual  inflammation  began.  The  development  and  persistence 
of  fever  and  pain  and  the  constant  occurrence  of  mucus  in  the  stools 
render  the  existence  of  inflammation  probable.  Intussusception  may 
simulate  ileocolitis  very  closely  at  the  onset;  both  conditions  exhibiting 
tenesmus  with  the  passage  of  bloody  mucus.  The  former  is,  however, 
characterized  by  the  more  sudden  onset  without  initial  fever,  the  com- 
plete lack  of  fecal  matter  in  the  stools,  the  absence  of  the  passage  of 
gas  from  the  bowels,  the  more  rapidly  developing  prostration,  and  the 
discovery  of  a  tumor, through  the  abdominal  walls  or  by  rectal  palpation. 
Typhoid  fever  in  infancy  exhibits  vague  symptoms  and  often  much  re- 
sembles ileocolitis;  and  indeed  the  pathological  lesions  are  often  much 
the  same.  The  onset  in  typhoid  fever,  however,  is  usually  less  abrupt 
and  there  is  no  tenesmus,  while  the  Widal  reaction  and  the  roseola  are 


ACUTE  ILEOCOLITIS  753 

characteristic.  Enlargement  of  the  spleen  may  occur  in  either  disease, 
but  is  more  common  and  more  marked  in  tj^phoid  fever.  Some  of  the 
severer  cases  of  ileocolitis  with  minor  intestinal  symptoms  and  marked 
cerebral  ones  may  readily  suggest  meningitis.  Although  diarrhea  of 
any  degree  is  a  contra-indication  to  the  presence  of  this,  yet  this  state- 
ment is  by  no  means  invariably  true,  and  the  diagnosis  may  be  one  of 
great  uncertainty. 

The  obtaining  of  an  agglutinative  reaction  with  the  blood  of  the 
patient  is  a  diagnostic  test  of  but  little  value.  It  does  not  appear  before 
the  2d  week,  and  is  "not  an  index  of  the  presence  of,  or  infection  with. 
Bacillus  dysenteriie"  (Flexner).^ 

So  far  as  any  differentiation  chnically  can  be  made  of  the  different 
forms  of  ileocolitis  from  each  other,  catarrhal  inflammation  is  indicated 
by  the  more  sudden  onset  and  the  greater  amount  of  mucus  and  blood 
in  the  stools,  with  tenesmus  and  abdominal  pain.  In  the  milder  cases 
of  this  form  the  temperature  soon  diminishes  and  the  mucus  and  strain- 
ing grow  less.  If  superficial  ulceration,  not  follicular,  is  present  the 
course  is  longer.  Follicular  ileocolitis  is  usually  secondary;  the  onset  is 
often  less  abrupt;  the  stools  contain  more  fecal  matter  and  little  blood, 
although  always  much  mucus;  tenesmus  and  pain  are  but  slightly 
developed;  the  temperature  is  lower  or  more  irregular,  and  the  course  is 
subacute.  The  membranous  variety  has  no  certain  characteristic  symp- 
toms except  the  possible  discovery  of  shreds  of  pseudomembrane  in  the 
stools.  Its  onset  may  be  sudden;  the  temperature  continuously  high; 
the  nervous  manifestations,  such  as  delirium,  marked.  The  mucus  and 
blood  in  the  stools  and  the  character  of  the  disease  in  general  may 
suggest  a  severe  case  of  the  catarrhal  form  of  the  disease.  In  other 
instances,  however,  the  intestinal  symptoms  are  vague  and  the  consti- 
tutional ones,  and  especially  those  of  a  cerebral  nature,  misleading  and 
lead  to  the  mistaken  diagnosis  of  a  meningitis. 

Treatment.  Prophylaxis. — The  same  methods  of  management  are 
to  be  followed  as  described  under  Acute  Gastroenteric  Intoxication, 
every  attention  being  given  to  the  maintaining  of  the  general  health, 
the  escape  from  excessively  hot  weather,  and  especially  the  guarding 
against  indigestible  food  or  that  containing  bacteria  in  excess.  The 
existence  of  other  diarrheal  diseases  being  a  powerful  predisposing  factor, 
such  must  be  treated  as  thoroughly  and  as  promptly  as  possible.  In 
addition  is  to  be  borne  in  mind  that  ileocolitis  is  an  infectious  disease 
and  that  the  spread  by  contagion,  although  probably  not  a  factor  of 
moment,  is  at  least  a  possibility,  and  precautionary  measures  may  well 
be  taken  against  this. 

Treatment  of  the  Attack. — Here  the  first  matter  to  be  considered 
is  the  diet.  Early  in  the  disease  milk  should  be  withdrawn  completely, 
and  this  applies  even  to  breast-fed  infants.  In  place  of  milk  such  articles 
should  be  given  as  broth  free  from  fat,  and  barley  water  or  other  thin 
cereal  decoction  except  oatmeal,  fre(iuently  and  in  small  amounts.  After 
a  day  or  two  breast-feeding  may  be  resumed;  but  in  the  case  of  artifi- 
cially fed  infants  a  somewhat  Umger  delay  in  returning  to  milk  is  ad- 
visable, until  the  acute  initial  .symptoms  subside.  The  strength  of  the 
food  must  now  necessarily  be  increased,  since  so  often  appetite  is  poor 
and  not  sufficient  nourishment  is  taken.  Among  foods  suitable  at  this 
time  are  stronger  cereal  decoctions  in  tiie  form  of  gruels,  which  sometimes 

'  Bacteriological  and  Clinical  Studies  of  Diarrlieal  Disorders  of  Infancy.  Hockc- 
fellcr  Institute,  1904,  1:35. 
48 


754  THE  DISEASES  OF  CHILDREN 

may  be  dextrinized  with  advantage,  but  with  caution  lest  diarrhea  is 
increased  thereby;  egg-water;  beef -juice  and  broths,  the  latter  to  be 
thickened  with  starchy  addition  and  often  containing  the  animal  fibre 
in  finely  divided  form.  Scraped  rare  beef  is  serviceable  in  older  infants. 
The  return  to  milk  must  be  made  with  great  caution,  and  this  at  once 
withdrawn  if  it  is  passed  largely  undigested  or  increases  the  symptoms. 
Whey;  skimmed  milk,  perhaps  peptonized;  casein  milk,  and  butter- 
milk are  often  of  great  value.  Only  trial  can  determine  the  food  best 
suited  to  the  case.  The  fat  of  the  milk  is  often  badly  borne  for  a  long 
time.  Although  food  should  be  given  frequently  and  in  small  amounts, 
it  must  not  be  administered  too  often  lest  the  intestinal  peristalsis  be 
increased.  In  man^^  cases  the  intervals  between  feedings  should  be 
lengthened.  Particular  care  is  to  be  observed  that  enough  nourishment 
is  taken,  since  the  course  of  the  disease  is  liable  to  be  prolonged.  Some- 
times the  loss  of  appetite  renders  feeding  by  gavage  necessary.  Water 
should  be  given  freely,  since  there  is  often  so  much  loss  of  liquid  from  the 
intestine.  Even  when  convalescence  is  advancing  the  ver}^  greatest 
care  in  diet  must  still  be  maintained,  perhaps  for  some  months,  since 
relapses  are  readily  brought  about  by  the  slightest  indiscretion.  In  the 
case  of  older  children  all  foods  of  the  green-vegetable  class,  or  those  with 
much  waste  material,  such  as  oatmeal,  and  all  fruits  must  be  carefully 
avoided. 

Hygienic  treatment  is  of  importance  likewise.  Abundance  of  fresh 
air  is  essential  yet  with  the  avoidance  chilling  of  the  body.  The  patient 
should  be  at  rest  in  bed.  Change  of  locality  is  often  of  great  value  in  the 
later  stages  of  the  long-continued  cases;  and  if  the  weather  is  hot  the 
patient  should  at  once  be  removed  to  the  seashore  or  mountains  at  any 
stage  of  the  disease. 

Medicinal  and  Local  Treatment. — At  the  beginning  of  the  attack  the 
child  should  receive  a  purgative  of  castor  oil,  calomel,  or  a  saline,  and  the 
bowels  should  be  well  washed  out  with  a  douch  of  normal  salt  solution. 
After  the  action  of  the  purgative  two  courses  are  open  so  far  as  drugs 
are  concerned.  One,  the  administration  daily  of  castor  oil  or  a  saline 
purgative  until  the  character  of  the  stools  changes;  the  other  the  giving 
of  bismuth  subcarbonate  in  6  to  10  grain  (0.39  to  0.65)  doses  every  2 
hours  at  2  years  of  age,  combined  with  opium.  If  there  is  reason  to  be- 
lieve that  irritating  material  has  been  thoroughly  removed  from  the  bowel 
I  prefer  as  a  rule  the  latter  plan,  although  the  former  is  often  very  effica- 
cious. The  continued  employment  of  lavage  of  the  intestine  2  to  3  times 
daily  with  water  either  warm  or  cool,  according  to  the  effect,  is  some- 
times very  successful,  using  from  1  to  2  quarts  (946  to  1892)  at  a  time. 
Either  a  normal  saline  solution  or,  often  preferably,  starch  water  may  be 
used  for  this  purpose.  In  very  many  instances,  however,  enemata 
after  a  time  increase  the  irritation  and  tenesmus  and  must  then  be 
promptly  abandoned.  The  employment  of  enemata  of  nitrate  of  silver, 
tannic  acid,  or  other  astringent  is,  in  my  experience,  oftener  harmful 
than  of  benefit,  as  it  is  liable  to  increase  the  tenesmus  or  to  cause  violent 
resistance  on  the  part  of  the  child.  If  used  at  all  they  should  be  decidedly 
weak,  not  more  than  0.25  to  0.5  per  cent,  of  tannic  acid  or  0.1  per  cent, 
of  nitrate  of  silver. 

Pain  and  tenesmus  are  to  be  treated  by  opium  in  sufficiently  large  doses, 
frequently  repeated.  The  employment  of  this  should  be  delayed,  if 
possible,  until  the  bowels  have  been  thoroughly  evacuated  by  the  initial 
purgatives  and  enemata.     Later  in  the  case  the  administration  of  some 


CHRONIC  ILEOCOLITIS.     CHRONIC  DIARRHEA  755 

tannic-acid  preparation-  by  the  mouth,  such  as  tannalbin  or  tannigen, 
is  sometimes  of  service,  still  combined  with  bismuth.  Acetate  of  lead, 
sulphate  of  copper,  ancl  nitrate  of  silver  in  small  doses  internally  are 
sometimes  employed.  Emetine  would  appear  to  be  a  specific  in  cases  of 
amebic  dysentery.  As  the  disease  is  an  exhausting  one  stimulants  are 
often  required  early,  given  in  doses  proportionate  to  the  age  (see  pp.  223, 
229),  bearing  in  mind  the  fact  that  children  tolerate  alcoholic  stimulants 
in  relatively  large  amounts.  Among  other  remedies  used  to  sustain  the 
strength  as  the  needs  demand,  are  digitalis,  strophanthus,  caffeine  and 
camphor,  best  given  hypodermicalty. 

Serum  therapy,  even  in  cases  proven  to  be  dependent  upon  the  dysen- 
tery-bacillus, has  not  appeared  as  yet  to  be  of  any  decided  value. 

During  co7ivalescence  great  care  must  be  taken  with  the  diet  on  the 
lines  already  indicated,  and  chilling  and  fatigue  of  the  body  guarded 
against,  since  relapses  so  readily  occur.  Tonic  remedies  are  indicated, 
especially  nux  vomica  and  often  iron. 

CHRONIC  ILEOCOLITIS.     CHRONIC  DIARRHEA 

These  two  disorders  are  practically  the  same,  any  diarrhea  which 
runs  a  decidedly  chronic  course  being  liable  to  be  finally  associated  with 
inflammatory  lesions  more  or  less  well  marked,  whatever  the  original 
cause  may  have  been. 

Etiology. — A  common  cause  is  an  attack  of  acute  ileocolitis  which, 
instead  of  disappearing,  has  passed  into  a  chronic  form.  In  other  very 
frequent  cases  the  disease  develops  insidiously  in  patients  who  have  been 
suffering  from  a  diarrhea  attending  rickets  or  other  chronic  debilitating 
disease,  or  who  have  had  long-continued  chronic  intestinal  indigestion 
from  persistently  faulty  feeding. 

Pathological  Anatomy. —  The  lesions  vary,  depending  somewhat 
on  the  original  disease.  Only  a  catarrhal  condition  of  the  mucous  mem- 
brane may  be  found.  To  the  naked  eye  there  maj^  be  little  alteration  in 
appearance,  except  some  thickening,  with  pigmentation  of  the  mucous 
membrane;  not  uniformly  but  in  patches  or  streaks,  or  seen  chiefly  in 
the  enlarged  solitary  glands  or  in  Peyer's  patches.  Microscopically 
a  decided  cellular  hyperplasia  is  found,  and  there  maj^  also  be  more  or  less 
cellular  proliferation  and  atrophy  in  the  epithelial  glandular  tissue  of 
both  the  large  and  the  small  intestine,  with  hypertrophy  of  the  connect- 
ive tissue.  In  the  less  frequent,  severer  cases,  especially  those  following 
severe  acute  ileocolitis,  there  may  be  decided  thickening  of  the  intes- 
tinal wall,  with  ulceration  or  with  evident  cicatricial  tissue  the  result  of 
the  healing  of  ulcers. 

Associated  with  th(>  intestinal  lesions,  changes  in  other  organs  are 
often  observed;  pneumonia  and  degenerative  alterations  of  the  kidneys 
and  liver,  the  latter  often  being  fatty,  and  enlargement  of  the  mesenteric 
lymphatic  glands  being  among  these. 

Symptoms.— These  are  largely  those  of  increasing  dei)ility  and 
marasmus,  coml)ined  with  diarrhea  and  other  digestive  disturbances. 
The  diarrhea  is  not  usually  severe  but  is  persistent  or  constantly  recur- 
ring. The  stools  are  looser  than  normal  although  not  very  thin;  number 
perhaps  2  to  0  daily;  ar(>  large  in  size;  sometimes  foamy  and  always  con- 
tain more  or  less  mucus,  with  undigested  food,  and  sometimes  pus  in 
small  amounts.  Blood  is  not  often  present.  The  odor  is  generally  very 
offensive;  the  color  either  dark  brown  or  light,  brown,  or  sometimes  green- 


756  THE  DISEASES  OF  CHILDREN 

ish  or  greyish.  The  abdomen  is  commonly  distended  with  gas.  Pro- 
lapse of  the  rectum  may  take  place,  although  less  often  than  in  the  acute 
cases.  Vomiting  is  not  common,  fever  is  absent  or  occurs  only  in  tem- 
porary outbreaks,  and  colic,  abdominal  tenderness,  and  tenesmus  may 
be  observed  but  are  not  as  frequent  as  in  acute  cases.  The  tongue  is 
coated  or  sometimes  dry  and  red ;  the  appetite  is  often  unaffected  or  is 
increased,  but  sometimes  very  poor.  The  general  health  is  greatly 
affected.  The  child  suffers  from  irritability  or  apathy,  malaise,  dis- 
turbed sleep,  poor  circulation,  dry,  rough  skin,  anemia,  and  emacia- 
tion which  is  sometimes  very  extreme.  There  is  a  very  persistent 
whining  cry.     A  marantic  dropsy  often  develops. 

Course  and  Prognosis. — The  course  is  essentially  chronic  but  is 
not  uniform.  Whether  death  or  recovery  finally  ensues  there  are  liable 
to  be  periods  of  transitory  improvement  followed  by  relapse.  In  other 
instances  a  temporary  disappearance  of  mucus  from  the  stools  may 
be  attended  by  the  development  of  fever.  In  the  cases  which  recover, 
in  which  the  intestinal  lesions  were  probably  of  lesser  severity,  half  a 
year  or  longer  may  go  by  before  convalescence  can  be  said  to  be  assured, 
and  even  then  the  general  health  may  not  yet  be  fulty  regained  and  the 
digestion  may  require  careful  watching  to  prevent  the  relapses  which  so 
frequently  occur.  The  fatal  cases  may  exhibit  improvement  at  times, 
but  may  grow  rapidly  worse  in  some  one  of  the  recrudescences,  and  the 
patient  die  from  exhaustion  or  from  some  complicating  intercurrent  dis- 
order, not  infrequently  bronchopneumonia.  Toward  the  end  of  life  an 
extensive  development  of  petechise  is  not  uncommon,  especially  on  the 
abdomen. 

The  prognosis  in,  general  is  always  serious,  and  difficult  to  formulate 
for  the  individual  case.  The  most  severe  cases,  given  up  by  physicians 
of  experience,  will  sometimes  eventually  recover.  If  intestinal  lesions 
are  marked  the  prognosis  is  very  unfavorable;  but,  inasmuch  as  we  can- 
not during  life  know  the  exact  severity  of  these,  an  absolutely  unfavor- 
able prognosis  must  be  given  with  reserve.  Those  patients  usually  die 
who  possess  little  general  strength,  are  under  unsatisfactory  conditions, 
and  in  whom  the  disease  has  already  lasted  for  some  time  without  any 
improvement. 

Complications  and  Sequels. — ^Bronchopneumonia  is  a  common 
complication.  Corneal  ulcers  are  sometimes  seen  as  are  purulent  otitis 
and  suppurative  processes  in  the  skin.  Thrush  is  common,  nephritis 
may  be  a  complication,  and  tuberculosis  a  not  infrequent  sequel. 

Diagnosis.^ — The  nature  of  the  disease  is  usually  sufficiently  evident 
in  well-developed  cases.  The  milder  forms  with  but  little  diarrhea 
cannot  always  be  sharply  distinguished  from  cases  of  chronic  intestinal 
indigestion.  The  diagnostic  features  are  the  large  amount  of  mucus 
constantly  occurring  in  the  stools,  and  the  presence  of  the  inflammatory 
characteristics  of  ileocolitis.  It  is  important  to  distinguish,  too,  as  far 
as  possible,  the  nature  of  the  cause,  inasmuch  as  this  has  such  an  impor- 
tant bearing  upon  the  prognosis.  When  the  disease  follows  an  acute 
ileocolitis,  if  this  has  been  severe  and  of  long  duration,  it  is  probable  that 
the  case  is  one  of  the  ulcerative  type.  If  it  has  developed  slowly  in  de- 
bilitated subjects  or  has  followed  a  chronic  intestinal  indigestion,  there 
is  greater  likelihood  of  it  being  catarrhal  or  follicular  without  ulceration. 
The  distinction  from  a  tuberculous  enteritis  is  often  difficult.  As  a 
rule,  however,  tuberculosis  of  the  intestine  is  a  later  manifestation  of 
this  disorder  already  evident  in  other  parts  of  the  body,  especially  the 


CONSTIPATION  757 

lungs;  the  onset  is  slow;  fever  is  present;  there  is  often  blood  in  the  stools 
and  there  already  exists  decided  involvement  of  the  general  health  out 
of  proportion  to  the  severity  and  the  duration  of  the  intestinal  symptoms. 

Treatment. — The  principal  treatment  is  dietetic  and  hygienic. 
In  the  matter  of  diet  only  trial  can  determine  the  food  best  suited  to  the 
patient,  the  examination  of  the  stools  being  of  aid  in  this.  Peptonized 
milk  preparations  are  of  service  in  occasional  instances,  especially  in 
infancy.  In  others  it  is  better  to  use  skimmed  milk,  since  the  fat  may 
be  not  well  tolerated.  In  other  instances  casein  milk  or  buttermilk  ans- 
wers well.  In  very  many  cases,  however,  milk  in  any  form  is  always 
passed  undigested  and  should  be  avoided,  and  broths  thickened  with  a 
starchy  addition  are  to  be  preferred.  Dextrinized  starchy  foods  are 
frequently  better  than  unconverted  starch;  yet  in  some  instances,  as  with 
broths,  increased  frequency  of  the  stools  may  result.  Beef  juice,  scraped 
beef  and  white  of  egg  are  often  very  serviceable. 

In  the  line  of  hygiene,  rest  combined  with  abundance  of  fresh  air  is 
very  important.  Massage  is  sometimes  of  value.  Precautions  must 
be  taken  as  far  as  possible  against  exposure  to  hot  weather,  by  removing 
the  child  to  the  seashore  or  the  mountains.  Indeed,  this  decided  change 
of  air  is  often  the  most  successful  treatment.  Large  enemata  of  saline 
solution  or  of  starch-water  are  useful  for  washing  out  the  bowels  when 
the  stools  are  more  abundant  than  usual,  or  should  any  temporary  consti- 
pation occurring  be  attended  by  unfavorable  symptoms.  They  should 
not  be  given  routinely,  but  with  frequent  interruptions  in  order  to  de- 
termine whether  or  not  their  employment  is  keeping  up  the  discharge  of 
mucus  from  the  bowel.  Astringent  enemata  are  probably  of  more  serv- 
ice than  in  the  acute  cases,  but  are  often  irritating. 

The  giving  of  drugs  by  the  mouth  is  a  very  minor  part  of  the  treat- 
ment. Bismuth  or  tannalbin  may  be  used  on  the  occasions  when  the 
frequency  and  thinness  of  the  stools  is  temporarily  increased.  If  this 
treatment  is  not  sufficient  and  there  is  reason  to  think  that  peristalsis  is 
too  active,  opium  may  be  given,  but  cautiously  and  not  continuously 
lest  constipation  develop,  with  consequent  exacerbation  of  the  fever  and 
other  general  sj^mptoms.  A  combination  of  opium  and  dilute  sulphuric 
acid  is  useful  in  some  instances.  Castor  oil  or  calomel  may  be  employed 
at  intervals  if  the  stools  are  unusually  offensive  or  if  there  has  been  a  rise  of 
temperature  appar&ntly  due  to  intestinal  intoxication,  and  it  is  even  serv- 
iceable without  these  indications.  It  may  be  necessary  to  administer 
alcohoUc  stimulants  freely  and  continuously  to  support  the  strength.  In 
some  cases  the  continued  administration  of  cod-liver  oil  has  proved  of 
benefit.  I  have  also  seen  improvement  follow  the  persistent  employment 
of  tincture  of  the  chloride  of  iron. 

CONSTIPATION 

Although  only  a  symptom,  constipation  is  one  of  extreme  importance 
and  freciuency  at  all  periods  of  life,  liy  the  term  is  indicated  evacuations 
which  are  (>ither  too  infreciuent,  too  small  in  amount,  or  too  firm  and  dry. 
The  title;  is,  however,  a  relative  one  and  is  applic:il)le  more  to  the  charac- 
ter than  to  the  frecjuency  of  the  stools,  unless  this  is  much  diminished, 
while  always  the  individual  habit  is  to  be  borne  in  mintl.  Some  in- 
fants, for  instance,  of  an  age  where  2  to  3  stools  should  occur  daily  have 
regularly  but  1,  and  should  not  therefore  be  called  constipated  if  the 
evacuation  is  of  sufficient  size  and  of  normal  character.  In  other  cases 
in  older  children,  where  but    1   movement  daily  is  to  be  expected,  there 


758  THE  DISEASES  OF  CHILDREN 

may  be  2  or  3,  but  these  may  be  hard  and  small  and  constipation  is 
present. 

Etiology. — The  causes  are  various  and  numerous,  and  the  etiological 
factors  are  not  the  same  at  different  periods  of  life.  Age  appears  to  have 
little  influence  in  determining  the  frequency.  In  the  new  born  entire 
absence  of  bowel-movements  may  depend  upon  atresia  of  the  anus  or 
imperforate  rectum,  or  upon  complete  obstruction  higher  in  the  course 
of  the  gastroenteric  tract.  (See  Intestinal  Obstruction,  p.  78.)  In  other 
instances  the  condition  at  this  early  age  is  less  serious,  and  a  temporary 
constipation  lasting  1  or  2  daj'-s  at  the  first  results  from  a  lack  of  tone  in 
the  intestinal  wall,  combined  with  the  fact  that  no  food  has  been  ingested. 
In  other  infants,  or  in  older  children,  constipation  may  depend  upon 
congenital  dilatation  of  the  colon ;  stenosis  of  the  pylorus  or  of  the  intestine 
at  some  portion;  appendicitis;  peritonitis;  strangulated  hernia;  fissure 
at  the  anus  which  causes  pain  at  stool  and  consequent  unwillingness  of 
the  child  to  make  the  necessary  effort;  hemorrhoids  acting  in  a  similar 
manner;  intussusception,  or  other  forms  of  intestinal  obstruction,  in- 
cluding the  blocking  of  the  intestines  by  a  foreign  body  or  by  a  large, 
hardened  mass  of  feces. 

Other  agencies,  however,  are  far  more  frequently  active  than  these 
mentioned.  A  predisposing  cause  of  a  constipated  habit  in  infants  is 
the  unusual  length  and  tortuous  course  of  the  sigmoid  flexure  character- 
istic of  this  period,  to  which  attention  was  called  by  Bednar^  and  especially 
by  Jacobi.2  The  character  of  the  diet  is  a  very  frequent  factor;  not 
uncommonly  constipation  in  infants  being  due  to  a  deficiency  in  the 
quantity  of  food  taken  or  in  the  strength  of  this,  or  to  a  lack  of  a  sufficient 
amount  of  some  one  of  the  ingredients.  A  breast-milk  or  a  bottle-mix- 
ture poor  in  fat  is  very  liable  to  produce  constipation ;  one  poor  in  protein 
does  the  same  to  a  less  extent.  Sometimes  too  fat  a  food  produces  con- 
stipated soap-stools.  In  the  case  of  some  infants  sterilizing  the  mixture 
is  a  cause;  in  others  the  addition  of  barley  water  or  any  other  similar 
cereal  decoction  may  occasion  the  trouble;  in  still  others  lime  water 
appears  to  act  in  this  manner.  It  is  largely  a  matter  of  individuality. 
After  the  age  is  passed  where  the  diet  should  consist  solely  of  milk,  con- 
stipation may  depend  upon  the  persistence  in  the  use  of  this  as  the  chief 
food  taken;  or  upon  the  limitation  of  the  diet  to  foods  which  are  too 
digestible,  such  articles  as  green  vegetables,  fruits,  and  those  cereals  like 
oatmeal  with  considerable  waste  matter  in  them  having  been  neglected 
largely  or  altogether. 

Perhaps  the  most  frequent  producer  of  constipation  is  a  certain  degree 
of  atony  of  the  intestinal  musculature.  Anything  which  causes  general 
debility,  such  as  rickets  or  anemia,  readily  gives  rise  to  this  lack  of  tone 
by  affecting  the  intestinal  muscles  and  those  of  the  abdominal  wall. 
Convalescence  from  any  disease,  and  especially  from  diarrheal  disturl)- 
ances,  is  likely  to  be  attended  by  constipation.  In  all  such  cases  of  loss 
of  tone  the  stools  may  be  of  normal  consistency  and  there  may  be  lacking 
onlj"  the  expulsive  power,  but  oftener  the  long  continuance  in  the  intestine 
has  been  followed  by  an  absorption  of  the  water  and  the  feces  are  too 
firm.  A  common  cause  of  failure  of  muscular  tone  is  lack  of  sufficient 
exercise;  and  consequently  the  trouble  is  more  common  in  children  in 
winter-time  from  the  greater  confinement  to  the  house  and  the  long 
sitting  in  school.     The  too  frequent  employment  of  enemata  or  of  purga- 

1  Die  Krankh.  d.  Neugoborenen,  1850,  I,  64;  128. 

2  Amer.  Journ.  Obstet.,  1869-70,  II,  96. 


CONS  TIP  A  TIOX  759 

tives  is  a  fertile  source  of  loss  of  muscular  power,  in  that  this  accomplishes 
artificially  what  the  intestine  should  do  of  itself.  Nervous  influences 
effect  greatlj^  the  intestinal  muscle.  The  failure  to  observe  regularity 
and  the  ignoring  of  the  sensation  of  a  desire  to  evacuate  the  bowel  will  soon 
develop  a  constipated  habit.  The  hurry  of  the  morning  hour  in  school 
children,  haste  or  other  disturbances  during  the  time  passed  in  the  toilet, 
and  many  similar  influences  are  effective.  Heredity  is  also  a  nervous 
factor  of  importance.  With  all  instances  of  lack  of  muscular  tone  there 
is  liable  to  be  combined  deficiency  in  the  secretory  action  of  the  intestine 
and  a  consequent  change  of  its  contents  from  the  normal  condition. 

Symptoms. — Constipation  may  be  either  acute  or  chronic.  The 
acute  form  may  be  congenital  and  persistent,  while  other  severe  acute  cases 
may  develop  dependent  upon  some  of  the  organic  causes  mentioned,  and 
attended  by  symptoms  of  these  disorders.  In  the  milder  acute  cases 
there  may  be  no  symptoms  whatever  other  than  the  constipation; 
or  the  condition  may  be  associated  with  evidences  of  indigestion,  colicky 
pain,  and  distention,  together  with  slightly  toxic  symptoms  such  as 
headache,  torpor,  fever,  and  similar  mainfestations,  which  seem  often 
to  be  dependent  upon  the  blocking  up  of  the  bowel,  and  which  not  infre- 
quently suggest  the  onset  of  some  acute  febrile  disease.  The  bowel- 
movements  in  acute  constipation  have  the  ordinary  character  of  the 
constipated  stool.  They  are  infrequent;  there  may  be  a  desire  to  evac- 
uate with  inability  to  accomplish  it;  and  when  finally  a  stool  is  passed 
after  straining  efforts  it  is  unduly  hard,  dry,  and  large,  and  perhaps 
streaked  slightly  with  blood  and  mucus.  The  condition  may  last  sev- 
eral days  with  onl}^  unsatisfactor}'-  stools  or  with  none  at  all. 

In  chronic  constipation  there  may  be  either  a  constant  repetition  of 
acute  attacks  with  short  intermissions,  or  the  bowels  may  be  persistently 
sluggish,  requiring  always  more  or  less  aid  to  relieve  them.  Sometimes 
there  is  never  an  evacuation  unless  artificially  obtained;  sometimes  there 
may  be  stools  passed  without  aid,  but  these  are  abnormally  firm  in 
character.  Symptoms  may  be  entirely  lacking  except-  the  constipated 
condition,  and  the  child  appear  in  good  health  in  other  respects;  but  fre- 
quently there  are  abdominal  pain  and  flatulence;  symptoms  of  indigestion 
in  general;  lossof  appetite;  occasional  fever:  sometimesvomiting;  anemia; 
high  colored,  scanty  urine  containing  indican  in  considerable  amount; 
and  various  norvous  symptoms,  including  headache,  disturbetl  sleep, 
and  even  convulsions.  Not  only  may  the  general  health  be  thus  affected, 
but  local  disturbances  may  arise,  such  as  fissures,  prolapse  of  the  anus, 
hernia,  or  hemorrhoids.  Not  infrequently  retained  fecal  masses  may 
be  felt  as  hard  nodules  through  the  abdominal  walls,  and  occasionally 
these  may  attain  a  tumor-like  size  and  hardness. 

Course  and  F^rognosis. — In  the  acute  cases  the  prognosis  depends 
upon  the  etiology.  Relief  is  obtained  in  a  few  days  when  the  disturbance 
is  from  acute  indigestion  and  similar  removable  causes,  while  in  those  due 
to  organic  ol)stru('tion  the  prognosis  is  serious.  Jn  the  chronic  functional 
cases  there  is  no  direct  danger  to  life,  but  the  course  is  indefinite  and 
more  prolonged  and  the  general  health  often  suffers  seriously.  \\  hi'n 
dependent  upon  chronic  dilatation  of  the  colon  the  prognosis  is  more 
serious. 

Diagnosis. — ^The  condition  is  generally  evident  from  the  history. 
One  may  sometimes  he  misle;!  l)y  the  statement  that  a  daily  evacuation 
of  the  bowels  occuis,  but  investigation  may  show  that  this  is  iiisulhcient 
and  that  in  fact  much  fecal  matter  is  being  retained  in  ihe  colon  with  the 


760  THE  DISEASES  OF  CHILDREN 

consequent  development  of  abdominal  distention,  evidences  of  indigestion, 
and  loss  of  health.  The  nervous  manifestations  attending  some  of  the 
acute  attacks  or  the  exacerbations  of  the  chronic  condition  may  simulate 
so  closely  the  onset  of  acute  infections,  including  meningitis,  that  difficulty 
in  diagnosis  mayatfirstexist;removedlater  by  the  prompt  recovery  follow- 
ing the  administration  of  a  purgative.  Fecal  concretions  in  the  colon 
discovered  by  palpation  may  sometimes  suggest  the  presence  of  a  tuber- 
culous peritonitis  or  of  morbid  growths.  A  careful  examination  combined 
with  a  study  of  other  symptoms  will  generally  remove  all  doubt. 

The  chief  object  of  diagnosis  is  to  discover  the  cause.  In  the  acute 
cases  this  is  imperative,  inasmuch  as  only  surgical  interference  can  avail 
for  the  relief  of  some  of  them ;  but  in  the  chronic  cases  also  it  is  of  impor- 
tance in  order  to  select  the  proper  treatment. 

Treatment. — Attention  must  be  given  in  acute  constipation  to  the 
immediate  unloading  of  the  bowel.  Where  the  constipation  is  complete 
and  depends  upon  organic  obstruction  operative  interference  is  required ; 
when  the  result  of  other  causes,  the  emptying  of  the  intestine  may  be 
accomplished  by  enemata  of  soap  and  water.  If  the  feces  are  very  hard, 
2  to  4  fl.  oz.  (59  to  118)  of  cotton-seed  oil  may  first  be  injected  and 
allowed  to  remain  for  a  few  hours;  and  if  the  mass  is  also  large  it  may  be 
necessary  carefully  to  break  it  up  with  the  finger  or  with  a  smooth- 
handled  teaspoon.  In  many  instances  of  brief  duration  a  soap-stick  is 
useful  in  the  case  of  infants,  or  a  glycerine  suppository  for  older  children. 
When  evidences  of  indigestion  accompany  the  constipation  a  cathartic 
is  more  serviceable,  using  calomel,  castor  oil,  or  milk  of  magnesia  in 
infants,  and  in  older  children  citrate  of  magnesia,  calcined  magnesia, 
castor  oil,  or  rhubarb. 

In  the  treatment  of  chronic  constipation  the  chief  attention  must  be 
given  to  the  cause.  As  this  is  oftenest  the  diet  it  may  be  considered  first. 
In  the  case  of  breast-fed  infants  aid  may  occasionally  be  obtained  by  a 
modification  of  the  mother's  milk  through  attending  to  her  own  diet  and 
h3^giene,  the  effort  being  made  to  augment  the  supply  and  increase  the 
total  solids  (see  p.  106),  if  examination  shows  these  to  be  deficient. 
In  bottle-fed  babies  some  alteration  of  the  diet  should  be  made.  The 
amount  of  fat  may  be  raised  cautiously  to  3  or  4  per  cent.,  if  this  is 
found  to  be  well  digested.  The  protein  should  not  be  too  high,  as  this 
appears  sometimes  to  favor  constipation,  but  on  the  other  hand  it  should 
seldom  be  less  than  1  per  cent,  or  proper  development  may  be  interfered 
with.  In  some  instances  the  use  of  oatmeal  water  or  of  bran-water  as  a 
diluent  is  of  benefit.  Orange  juice  is  often  serviceable,  as  is  the  adminis- 
tration daily  of  1  to  2  fl.  drams  (3.7  to  7.4)  of  olive  oil.  In  infants  past  the 
1st  year,  and  in  older  children,  food  may  be  selected  of  a  laxative  nature 
suitable  to  the  age.  The  amount  of  cream  used  on  the  cereal  may 
be  advantageously  increased  in  many  instances,  and  the  quantity  of 
whole  milk  diminished.  Fruit  juices,  and,  later,  fruits  themselves,  are 
excellent;  especially  to  be  mentioned  here  being  prune  juice.  For  older 
children  figs  and  dates  in  moderate  quantities  do  well  if  well  digested. 
Such  green  vegetables  as  spinach,  asparagus  tips,  and  string  beans,  and 
such  flours  as  oatmeal  and  Graham  are  of  the  laxative  class.  Bran- 
biscuits^  made  at  home  are  frequently  serviceable.  These  are  quite 
palatable,  and  may  be  rendered  still  more  so  if  broken  and  served  with 

1  Recipe  for  bran-biscuit:  Mix  1  pint  of  bran,  J^  pint  of  flour,  and  1  level  table- 
spoonful  of  baking  soda.  Mix  I2  pi'^t  of  milk  and  4  tablespoonfuls  of  molasses. 
Add  this  to  the  bran-mixture  and  bake  in  gem-pans. 


CONSTIPATION  761 

milk  and  sugar.  Increase  in  the  amount  of  butter  is  often  efficacious  and 
a  piece  of  butter  may  be  given  once  or  twice  a  day  to  a  child  of  2  j^ears  in 
addition  to  that  used  on  bread  and  with  vegetables.  Broth  frequently 
exerts  a  laxative  action  through  the  salts  contained  in  it,  and  dextrinizing 
the  cereal  porridges  with  a  malt-extract  (see  p.  155)  may  sometimes  be 
done  to  advantage.  In  general  those  articles  of  diet  which  are  largely 
digested  and  absorbed,  such  as  the  protein  of  milk  and  foods  consisting 
chiefly  of  starch,  should  be  restricted  in  amount,  and  those  of  fat  nature 
or  containing  much  waste,  such  as  green  vegetables,  many  fruits,  and  the 
outer  coating  of  the  grain,  increased.  When  the  constipation  is  simply 
one  of  the  symptoms  of  chronic  intestinal  indigestion,  the  dietary  sug- 
gested may  be  entirely  inadmissible,  and  produce  symptoms  much  more 
troublesome  than  the  constipation.  In  such  cases  the  food  must  be 
selected  which  is  suitable  for  the  digestive  disturbance,  and  other  means 
employed  to  relieve  the  constipation. 

Training  is  of  great  importance  at  anj^  age.  Even  when  but  a  few 
months  old  a  regular  habit  is  favored  by  holding  the  infant  in  the  nursery- 
chair  at  the  same  hours  dail3^  Older  children  should  be  compelled  to  give 
opportunity  for  the  bowel  to  empty  itself  at  a  fixed  hour,  at  a  time 
when  the  inclination  is  most  strongly  felt  and  when  there  is  nothing  to 
cause  hurry.  Shortly  after  breakfast  is  generally  a  suitable  time,  since 
the  eating  of  food  increases  the  intestinal  peristalsis  and  often  produces 
the  desire  for  an  evacuation.  The  disposition  of  children  is  to  resist 
this  desire  unless  they  are  instructed  never  to  do  so.  Hard  straining  is 
of  course  not  to  be  encouraged;  but  a  sufficient  time,  15  minutes  or  even 
a  half  hour,  allowed  in  the  toilet  will  often  be  followed  by  a  stool,  even 
though  at  first  no  inclination  is  felt;  and  a  child  should  be  taught  that 
it  can  do  nothing  in  the  way  of  play  or  other  amusement  until  the  bowels 
have  been  opened. 

Exercise  and  massage  are  often  very  valuable.  Abdominal  massage 
applied  daily  by  one  understanding  it  properly  is  of  help  both  with  infants 
and  with  older  children.  Not  only  should  the  abdominal  muscles  be 
kneaded  to  increase  tone,  but  by  a  pushing  movement  with  the  flat  of  the 
hand  along  the  course  of  the  colon,  the  intestinal  muscles  are  reached  and 
the  fecal  matter  aided  in  its  course  through  the  gut.  Abundant  ex- 
ercise on  the  part  of  the  child  is  a  decided  aid.  I  have  seen  most  ob- 
stinate chronic  constipation  promptly  relieved  by  the  removing  of  the 
patient  to  a  hilly  summer-resort,  apparently  through  the  greatly  in- 
creased amount  of  exercise  taken. 

If  constipation  persists  in  spite  of  a  proper  diet  and  of  careful  training 
and  exercise,  medicinal  measures  antl  other  allied  treatment  must  be  em- 
ployed to  supplement  these.  Thej'  should,  however,  be  used  no  oftener 
than  necessary  and  discontiiuied  as  soon  as  jjossible.  Suppositories  are 
of  service  in  this  connection.  These  maj'  be  of  soap,  gh'rerine  and  soap, 
or  gluten.  Sometimes  the  introduction  of  the  oiled  thermometer-stem 
gives  all  the  local  stimulus  to  contraction  that  an  infant  re(iuires.  (ilyc- 
erine-suppositories  are  too  irritating  for  constant  use.  In  the  training 
of  children  to  a  daily  habit  suppositories  may  be  used  if  no  stool  is  ob- 
tained after  a  sufficient  time  has  been  passed  in  the  chair  or  toilet.  In 
a  short  while  it  is  probal)le  that  this  measure  will  l)e  no  longer  required, 
l^nemata  are  also  useful  in  empt.ying  the  bowels  in  chronic  constipation, 
but,  like  sujipositories,  should  not  be  employed  as  a  routine  measure. 
They  siiould  be  small  unless  there  is  reason  to  believe  that  there 
is    a    large    fecal    accumulatioii.     Small    injections    of    cotton-seed    or 


762  THE  DISEASES  OF  CHILDREN 

other  bland  oil  are  the  least  irritating  and  are  employed  to  soften  the 
feces;  somewhat  larger  ones  of  well-diluted  glycerin  (1:10)  are  serv- 
iceable when  there  is  lack  of  tone;  and  still  larger  ones  of  normal  salt- 
solution  for  infants,  or  of  soap  and  water  at  this  age  or  in  older  children, 
where  there  has  been  no  passage  for  several  days.  Enemata  are  less 
serviceable  than  suppositories  when  only  local  stimulation  is  required, 
as  they  lose  then-  effect  and  need  to  be  constantly  increased  in  size. 
One  of  the  most  successful  courses  of  treatment  in  chronic  constipation 
is  the  giving  nightly  on  retiring  an  enema  of  sweet  oil  of  from  2  to  6  fl.oz. 
(59  to  177)  or  more,  depending  upon  the  age  of  the  child  and  the  toler- 
ance of  the  bowel.  In  the  morning  the  clesire  for  an  evacuation  will 
probably  be  present  and  the  softened  stool  passed  without  difficulty. 
In  obstinate  cases  it  may  at  first  be  necessary  to  administer  a  saline  laxa- 
tive in  small  dose  before  breakfast,  but  the  need  of  this  generally  soon 
ceases.  Stretching  of  the  anal  sphincter  is  occasionally  very  serviceable 
in  the  instances  where  great  spasm  of  the  muscle  is  present  or  where 
evacuation  is  evidently  painful.  This  is,  however,  seldom  necessary,  the 
difficulty  being  overcome  by  other  measures. 

Treatment  with  drugs  by  the  mouth  is  to  be  mentioned  last,  because, 
although  often  necessary,  it  is  to  be  deprecated.  In  infancy  some  mild 
remedy  added  to  the  bottle-food  is  often  of  great  service.  Here  may  be 
mentioned  manna  (5  to  10  grains)  (0.32  to  0.65),  phosphate  of  soda 
(5  to  20  grains)  (0.32  to  1.3),  or  milk  of  magnesia  {^i  to  1  fl.  dram) 
(2  to  4).  Castor  oil,  although  laxative,  commonly  leaves  constipation  in 
its  train,  and,  like  calomel,  should  be  reserved  for  times  when  distinct 
evidences  of  indigestion  are  also  present.  Some  of  the  less  bitter  prepara- 
tions of  cascara  in  doses  determined  by  trial  are  of  great  service.  Senna 
and  phenolphthalein  are  useful  drugs,  and  the  syrupy  malt  extracts  are 
often  efficacious.  It  is  a  good  plan  to  continue  no  one  of  these  substances, 
or  indeed  any  other  measure,  without  change.  Thus  the  giving  of  a 
laxative  may  be  replaced  after  a  few  days  by  the  use  of  suppositories  or 
by  enemata.  In  this  way  the  acquiring  of  a  tolerance  for  the  treatment 
is  avoided  as  much  as  possible. 

In  subjects  past  the  period  of  infancy  the  same  internal  remedies  may 
be  employed  in  larger  amount,  or  such  drugs  used  as  sulphate  of  magnesia 
with  syrup  of  rhubarb,  syrup  of  senna  with  cascara,  phenolphthalein  in 
small  dose,  or  one  of  the  laxative  mineral  waters  before  breakfast.  The 
same  precautions  should  be  taken  as  in  infancy  against  the  patient  be- 
coming accustomed  to  any  one  measure.  Among  some  of  the  other 
remedies  recommended  for  either  infancy  or  children  are  agar-agar, 
exodin,  purgen,  purgatin  and  petrolatum  liquidum.  Agar-agar,  accord- 
ing to  Schmidt^  contains  0.6  per  cent,  of  cellulose  and  acts  purely 
mechanical^.  It  may  be  mixed  with  a  cereal  and  given  in  the  form  of  a 
porridge.  Liquid  paraffin  (petrolatum  liquidum)  is  one  of  the  most 
popular.  This,  too,  acts  mechanically,  and  may  be  administered  plain 
or  made  into  an  emulsion  with  an  aromatic  water.  Children  old  enough 
to  take  pills  may  receive  small  doses  of  aloin  or  of  podophyllin.  At  all 
ages  drugs  which  increase  the  tone  of  the  intestinal  or  abdominarmuscles 
are  useful,  especially  to  be  mentioned  being  nux  vomica. 

1  Munch,  mod.  Wochenschr.,  1905,  1970,  Oct.  10. 


CHRONIC  INTESTINAL  INDIGESTION  763 

CHRONIC  INTESTINAL  INDIGESTION 

This  exceedingly  common  disorder  affecting  both  infants  and  older 
children  is  very  frequently  associated  with  gastric  indigestion,  but  prob- 
ably still  oftener  occurs  alone.  It  is,  strictly  speaking,  a  purely  func- 
tional disturbance,  yet  in  symptoms  it  may  sometimes  not  be  readily 
distinguishable  from  mild  cases  of  ileocolitis  characterized  bj'  actual  in- 
fllanuiiatory  lesions.  It  is  one  of  the  most  difficult  diseases  to  treat,  espe- 
cially in  infancy. 

A,  Chronic  Intestinal  Indigestion  in  Infants 
(Intestinal  Dyspepsia;  Decomposition) 

Etiology  and  Pathology. — The  disease  is  much  oftenest  seen  in 
the  1st  year  of  hfe  and  especially  in  the  first  6  months.  Poor  hygienic 
surroundings  predispose,  as  does  very  greatly  a  congenital  constitutional 
debility.  This  last  is  a  common  factor,  the  infants  in  many  cases  haying 
been  born  prematurely  or  being  the  offspring  of  tuberculous  or  syphihtic 
parents,  or  of  others  with  some  unfavorable  constitutional  influence  in 
the  way  of  parentage.  Among  frequent  causes  is  the  occurrence  of 
attacks  of  acute  intestinal  indigestion  or  acute  ileocohtis.  Of  all  etiolog- 
ical factors,  however,  the  continued  employment  of  an  unsuitable  diet  is 
by  far  the  most  influential  and  common.  It  is  on  this  account  that  the 
disease  is  much  oftener  seen  in  those  artificially  fed,  although  it  is  true  that 
breast-fed  infants  may  readily  develop  it  if  the  breast-milk  is  of  unsuit- 
able character. 

In  breast-fed  children  the  fault  is  sometimes  easily  ascertained.  The 
quantity  of  milk  secreted  by  the  mother  and  taken  by  the  child  may  be 
constantly  too  great.  In  other  instances  the  supply  is  far  from  sufficient 
and  the  infant's  general  health  consequently  suffers,  until  finally  the 
intestinal  functions  are  so  weakened  that  an  amount  of  food  which  will 
be  properly  nourishing  cannot  be  assimilated.  In  still  others — and 
these  the  most  frequent  of  all — some  of  the  constituents  of  the  breast- 
milk  are  easily  discovered  to  be  secreted  in  excess.  Many  times,  however, 
analysis  reveals  nothing  whatever  which  can  account  for  the  persistent 
indigestion  present.  Sometimes  it  appears  to  be  some  constitutional 
trouble  with  the  nursing  mother,  as  when,  for  instance,  she  is  of  a  highly 
neurotic  temperament,  or  shows  other  evidences  of  ill  health,  although 
the  way  in  which  the  milk  is  affected  is  not  discoverable. 

In  the  case  of  nrtijicially  fed  infants  the  fact  that  the  diet  is  necessar- 
ily an  unnatural  one  renders  it  unfit  in  any  form  for  many  infants,  and 
chronic  indigestion  is  an  unavoidable  result.  The  chemical  differences  in 
the  proteins  and  fats  make  it  impossible  to  prepare  a  milk  modification 
exactly  hke  human  milk,  and  in  addition  is  the  lack  of  similarity  in  the 
ferments,  salts  and  other  l)0(lies,  the  importance  of  the  action  of  which 
is  still  little  understood.  Oftener  there  is  a  very  evident  and  clearly 
recognizable  fault  with  some  one  of  the  ingredients,  an  amount  of  this 
being  given  which  the  digestion  cannot  tolerate.  Besides  this  comes 
prominently  into  play  in  bottle-fed  l)abies  the  element  of  infection  of 
the  milk  by  germs  of  various  sorts.  (See  Acute  Oastroenteric  Intoxica- 
tion, p.  738.)  Finally  it  frequently  happens  in  well-atlvanced  cases 
that  although  a  change  in  an  unsuit.able  milk  mixture  would  have  been 
efficacious  if  made  earlier,  the  infant  when  coming  under  ob.servation  has 
reached  a  condition  where  no  alterations  of  the  diet  attempted  have  any 


764  THE  DISEASES  OF  CHILDREN 

beneficial  effect,  the  child  being  unable  to  make  use  of  the  elements 
supplied. 

Just  what  the  principal  defects  in  the  diet  may  be  in  cases  in  bottle- 
fed  infants  is  a  matter  much  discussed  and  far  from  ultimately  settled. 
This  subject  has  already  been  considered  to  some  extent  elsewhere.  (See 
Action  of  the  Different  Food  elements  in  Digestion,  pp.  99,  127,  178; 
Finkelstein's  Classification,  p.  697;  Feces  in  Disease,  p.  731.)  Un- 
doubtedly too  much  blame  was  formerly  placed  upon  an  excess  of 
protein,  and  especially  of  casein;  and  the  disposition  now  is  in  many 
quarters  to  attribute  indigestion  solely  to  the  whey,  the  carbohydrates, 
or  the  fat.  Physicians  who  have  repeatedly  seen  good  results  from 
the  use  of  whey  hesitate  to  assign  to  it  all  the  evil  influences  claimed 
by  some  observers.  Doubtless  there  is  some  middle  ground  of  behef 
which  will  eventually  be  established.  There  is  at  any  rate  a  very  general 
agreement  at  the  present  time  that  the  fat  of  the  milk  is  one  of  the  in- 
gredients most  difficult  to  digest.  Less  often  the  sugar  causes  trouble, 
but  to  what  extent  this  is  an  independent  action,  or  how  much  it  acts 
synergetically  with  other  elements  of  the  food  is  still  uncertain.  The 
addition  of  amylaceous  food  to  the  nourishment  aids  digestion  in  many 
cases;  and  in  others  is  certainly  the  cause  of  chronic  intestinal  indigestion. 
Many  of  the  proprietary  infant's  foods  probably  act  harmfully  through 
the  high  percentage  of  unconverted  starch  present. 

The  whole  matter  is  still  in  the  process  of  solution.  It  must  be  rec- 
ognized, however,  that,  although  there  may  be  a  general  rule  evolved, 
and  although  fat  indigestion  is  certainly  a  very  common  form,  yet  the 
question  is,  to  some  extent,  an  individual  one  and  has  to  be  determined 
largely  for  each  child. 

Here  may  be  again  mentioned  the  fact,  emphasized  by  many  writers, 
that  the  trouble  appears  not  always  to  be  in  the  intestine  itself,  although 
perhaps  primarily  so,  but  in  the  defective  metabolism  in  the  tissues  of  the 
body.  This  is  particularly  true  of  the  advanced  cases  where  the  condition 
of  infantile  atrophy  (p.  610)  finally  develops.  It  is  not  only  the  failure  to 
absorb  food  to  a  sufficient  extent  which  is  at  work  in  these  cases,  but  the 
harmful  action  of  abnormal  substances  produced  in  the  intestines  or  in 
the  tissues. 

Pathological  Anatomy.^ — ^In  typical  cases  there  are  no  lesions  found, 
the  disease  being  a  purely  functional  disturbance.  In  advanced  cases, 
however,  complicating  secondary  lesions  appear,  among  them  inflamma- 
tion of  the  intestinal  mucous  membrane.  The  disorder  then  has  changed 
to  a  condition  of  chronic  ileocolitis. 

Symptoms. — In  some  cases  there  is  constant  diarrhea,  the  stools 
being  watery,  greenish,  and  containing  curdy  masses  of  various  sizes. 
The  number  is  seldom  large,  they  are  passed  without  pain,  and  mucus  is 
seen  in  small  amount  only,  if  at  all.  If  later  in  the  disease  there  is 
constantly  a  large  amount  of  mucus  present,  it  is  probable  that  a  chronic 
ileocolitis  of  mild  grade  has  developed.  In  other  cases  the  stools  are  only 
occasionally  diarrheal,  or  there  xway  be  a  chronic  constipation,  the  pas- 
sages often  being  pasty  and  too  light  in  color  and  sometimes  hard,  either 
in  small  scybalous  masses,  or  in  larger  form  with  difficulty  in  evacuation 
and  requiring  enemata  or  purgatives.  In  any  event  microscopical  and 
chemical  examination  often  reveals  undigested  food,  especially  fat;  free, 
or  in  the  form  of  soap.  The  odor  of  the  stool,  whether  loose  or  formed,  is 
generally  unpleasant  or  sour;  and  occasionally  offensive  if  there  is  decom- 
position of  proteid  material  going  on.     Vomiting  occurs  occasionally  in 


CHRONIC  INTESTINAL  INDIGESTION 


765 


most  instances,  but  is  not  a  constant  or  troublesome  symptom  unless 
the  disease  is  complicated  by  gastric  indigestion.  The  abdomen  is  usually 
distended  by  gas  and  there  is  frequent  colic  if  constipation  is  present,  but 
less  often  so  if  diarrhea.  The  appetite  is  generally  good  and  sometimes 
large;  the  tongue  varies;  there  is  often  irregular  fever  alternating  with  nor- 
mal or  low  temperature,  or  there  may  be  more  constant  elevation,  but 
only  when  symptoms  of  constitutional  intoxication  develop.  The  urine 
may  show  the  presence  of  the  acetone  bodies  and  an  increased  output  of 
nitrogen  in  the  form  of  ammonia,  but  this  is  not  always  the  case.  In 
some  patients  there  arises  an  intolerance  for  cow's  milk  in  any  form, 
its  administration  being  followed  by  an  exacerbation  of  the  symptoms, 
including  vomiting,  diarrhea,  fever,  and  sometimes  cutaneous  eruptions 
and  evidence  of  a  disturbed  nervous  state. 

The  chief  symptom,  however,  is  -persistent  increasing  malnutrition, 
with  all  the  symptoms  already  described  under  the  heading  of  infantile 


Fig.  252. — Chronic  Intestinal  Indigestion. 
Child  of  3j^  months,  in  the  Children's  Hospital  of  Philadelphia.     Great  wasting;  mod- 
erate fever;  bowels  loose;  failure  to  improve  under  any  treatment;  death. 


atrophy  (pp.  612  and  698).  The  children  gradually  waste  more  and  more, 
and  suffer  from  low  temperature,  feeble  circulation,  anemia,  and  in- 
creasing debility.  They  are  usually  constantly  fretful  in  the  early  stage 
and  often  apathetic  later.  During  this  condition  of  malnutrition  no  very 
positive  evidences  of  indigestion  may  be  discoverable.  Yet  diminishing 
the  amount  of  food  of  these  infants  may  increase  the  rapid  loss  of  weight, 
while  increasing  the  amount  may  have  the  same  effect,  often  with  attacks 
of  autointoxication  of  a  dangerous  nature. 

Course  and  Prognosis. — The  course  of  the  disease  is  very  variable 
and  the  duration  uncertain.  At  best  it  is  long-continuetl  and  lasts  for 
months  before  recovery  is  assured.  In  some  instances  the  loss  of  weight 
is  constant  and  extreme  (Fig.  252).  In  others  there  may  be  long  periods 
during  which  it  is  stationary  or  even  in  which  temporary  improvement 
and  increase  of  weight  occur,  to  be  followed,  however,  by  relapse.  In 
still  others,  not  too  far  advanced  when  cominji  under  observation,  there 
is  eventually  a  more;  or  less  steady  increase;  of  weight  and  return  to  gen- 
eral health.  In  ncvirly  all,  however,  there  are  lial)le  to  be  exacerbations, 
depending  piobal^ly  upon  intercurrent  acute  dys|)eptic  disturbances  of 


766 


THE  DISEASES  OF  CHILDREN 


the  stomach  and  intestines  perhaps  advancing  to  the  stage  of  intestinal 
toxemia.  Vomiting  may  then  for  a  time  become  troublesome  or  diarrhea 
be  a  marked  symptom,  while  fever  develops,  and  the  nervous  symptoms 
characteristic  of  the  condition  (pp.  698  and  741)  may  appear  (Fig.  253). 
The  prognosis  is  always  serious,  especially  in  cases  with  diarrhea, 
and  in  those  others  in  which,  with  little  active  intestinal  disturbance, 
improvement  in  weight  fails  to  take  place  no  matter  what  change  in  diet 
is  made.     In  the  majority  of  such  cases  death  follows  finally  from  exhaus- 

tion  or  intoxication,  perhaps  during 

an  exacerbation. 

The  earlier  in  the  disease  the 
treatment  is  commenced  the 
greater  is  the  chance  of  recovery. 
On  the  other  hand,  an  infant  who 
has  long  tolerated  the  disorder  may 
be  assumed  to  possess  greater  re- 
sisting power.  Serious  although 
the  disease  is,  even  apparently 
hopeless  cases  sometimes  recover 
under  proper  treatment,  but  with- 
out this  there  is  little  chance  for 
improvement.  There  is,  moreover, 
constant  danger  of  relapses  from 
slight  or  undiscoverable  causes. 
When  recovery  does  take  place  it 
is  usually  finally  complete  and  the 
condition  of  the  child  in  the  2d  or 
3d  year  seems  often  to  be  no  worse 
as  a  result  of  the  illness  in  the  1st 
year  of  life.  Some  patients,  how- 
ever, continue  delicate,  or  later 
suffer  more  or  less  from  intestinal 
disturbances. 

Complications.^ — These  are 
numerous  and  are  largely  those 
described  under  ileocolitis  and 
consisting  of 
thrush,  erythema  and  intertrigo 
especially  of  the  anal  region  if  there 
is  diarrhea,  furunculosis  or  other 
suppurative  processes  of  the  surface 
of  the  body,  suppurating  otitis, 
and  atalectasis.  There  may  be 
widespread  petechias  before  death, 
and  often  terminal  pneumonia, 
nephritis,  or  convulsions  may  develop.  The  disease  may  readily  pass 
into  an  ileocolitis  of  a  chronic  nature  and  result  fatally. 

Diagnosis.^ — The  advanced  cases  are  to  be  distinguished  chiefly 
from  infantile  atrophy  depending  upon  other  causes,  such  as  congenital 
asthenia,  tuberculosis,  and  syphilis.  The  history  of  early  digestive 
troubles  preceding  the  atrophy  is  generally  sufficient  to  confirm  the  diag- 
nosis of  chronic  intestinal  indigestion,  if  no  positive  symptoms  of  constitu- 
tional disorders  contraindicate  this.  The  diagnosis  is  also  to  be  made 
from  milder,  long-continued  cases  of  chronic  ileococlitis.     Both  diseases 


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Fig.  253.- — Exacerbation  of  Symptoms 
IN  A  Case  of  Chronic  Intestinal 
Indigestion. 

George  B.,  aged  6  months.  In  the 
Children's  Hospital  of  Philadelphia  for-  infantile  atrophv 
chronic  intestinal  indigestion.  Occasional 
vomiting;  2  to  3  slightly  undigested  and 
diarrheal  stools  daily;  much  emaciated. 
Dec.  12,  suddenly  developed  apathy; 
toxemic  symptoms;  prostration;  distended 
abdomen;  5  to  7  diarrheal  stools  daily, 
greenish,  with  pus  and  mucus;  increase  of 
temperature.  Weight  7  pounds,  7  ounces. 
(3374.)    Final  recovery. 


CHRONIC  INTESTINAL  INDIGESTION  767 

produce  wasting  and  exhibit  disturbances  of  the  stools;  but  in  indigestion 
these  stools  fail  to  show  the  constant  large  amount  of  mucus  which  is 
diagnostic  of  chronic  ileocolitis.  As  already  stated,  the  passing  of  the 
functional  into  the  inflammatory  disorder  is  of  great  frequency.  The 
recognition  of  the  cause  of  the  chronic  intestinal  indigestion  is  important 
but  often  very  difficult.  A  careful  consideration  of  the  earlier  histor}^  of 
the  case,  with  special  reference  to  the  nature  of  the  diet  employed,  is 
frequently  a  great  aid  in  this  direction.  An  excess  of  carbohydrate  in  the 
food  produces  colic  and  very  possibly  watery,  irritating,  acid  movements, 
often  with  an  penetrating  acid  odor  suggesting  acetic  acid;  sometimes 
offensive,  if  there  is  a  combined  protein-indigestion.  Excess  of  protein 
may  occasion  either  constipated  or  diarrheal  stools  with  a  putrefying 
odor,  and  protein-curds  may  be  present.  Excess  of  fat  may  also  result 
in  either  constipation  or  diarrhea.  In  the  former  the  stools  are  of  a  grey 
or  white  color,  are  composed  largely  of  insoluble  fatty  soaps,  and  may  have 
an  unpleasant  smell.  When  diarrhea  is  the  symptom  the  stools  may  be 
pale-yellow,  with  a  sour  or  offensive  odor,  more  or  less  glistening  from  the 
presence  of  fat,  and  reveal  under  the  microscope  fat-globules  and  crystals 
in  excess.  In  many  other  cases  they  are  watery,  mucous,  greenish,  and 
with  numerous  curdy  masses  of  a  whitish  color.  (See  Feces  in  Digestive 
Diseases,  p.  731.) 

Treatment.^ — Medicinal  treatment  is  purely  symptomatic.  Con- 
stipation is  to  be  relieved  by  enemata  or  gentle  laxatives;  occasionally 
by  free  purgation  if  there  are  symptoms  of  acute  gastric  or  intestinal 
indigestion.  Diarrhea  may  be  checked  by  appropriate  means.  (See  Acute 
Intestinal  Indigestion,  p.  736.)  Cohc  is  to  be  treated  by  measures 
already  referred  to  for  this  disorder  (p.  730).  The  strength  must  be 
sustained  by  stimulants,  the  body  temperature  by  external  heat.  During 
exacerbations  brief  starvation  must  be  instituted  and  a  purgative  given. 
This  is  especially  true  if  symptoms  of  intoxication  have  appeared. 

In  the  line  of  hygienic  treatment,  care  is  required  that  the  infant 
have  plenty  of  fresh  air.  This  is  a  matter  of  great  importance.  It  is 
well  recognized  that  infants  with  malnutrition,  confined  to  close  hospital 
wards,  do  not  thrive,  whether  chronic  intestinal  indigestion  or  other 
disorders  be  operative.  The  infant  ma}^  be  kept  in  bed  and  the  windows 
of  the  room  open;  or  if  well  enough  be  taken  out  of  doors  daily,  the 
bodily  temperature  in  cool  weather  being  maintained  by  the  free  use  of 
hot-water  bottles.  It  is  only  when  the  infant's  temperature  is  decidedly 
subnormal,  or  when  exposure  to  cooler  air  is  followed  by  a  dangerous 
depression  of  the  child's  temperature  in  spite  of  efforts  to  prevent  this, 
that  the  airing  described  must  be  avoided.  In  such  cases  the  infant 
must  perforce  be  kept  in  a  well-warmed  room  until  sufficiently  improved 
to  bear  the  cooler  air.  In  very  feeble  infants  rubbing  the  body  under  the 
covers  with  warm  oil  should  replace  the  bath.  In  others  a  dail}' sponge- 
bath  or  tul)-bath  is  of  advantage,  provided  a  good  reaction  follows. 

By  far  the  most  important  treatment,  however,  is  dietetic,  and  this 
is  frequently  one  of  the  most  difficult  problems  which  the  physician  ever 
encounters.  In  the  cases  of  chronic  indigestion  in  bread-fed  infants  too 
great  haste  must  be  avoided  in  advising  weaning.  I  cannot  too  strongly 
insist  upon  this  point.  Sometimes  a  regulation  of  the  mother's  diet  and 
method  of  life,  or  some*  alteration  in  the  fictiuencv  of  fcHHJing  tlu*  infant 
will  suffice.  In  other  cases,  th(>  eniploynuMit  once  or  twic(>  daily  of  an 
artificial  food  may  answer,  br(>ast-milk  being  still  the  principal  diet;  since 
the  giving  of  even  a  small  amount  of  iiunum  milk  seems  fr(Mjuently  in 


768  THE  DISEASES  OF  CHILDREN 

some  way  to  enable  the  infant  to  digest  more  satisfactorily  a  diet  largely 
artificial.  Some  infants  in  spite  of  evident  failure  to  digest  breast-milk 
perfectly  continue  to  thrive  in  other  respects,  and  in  such  it  is  certainly 
well  to  delay  the  withdrawing  of  breast-feeding,  inasmuch  as  there  is  no 
surety  that  artificial  feeding  may  not  have  a  worse  result.  The  tempo- 
rary withdrawal  of  the  breast  for  24  or  more  hours  at  a  time  may  suffice  in 
such  cases.  When,  however,  the  indigestion  is  persistent  and  the  child 
is  losing  ground  in  spite  of  faithful  efforts  to  remove  the  difficulty,  either 
the  employment  of  a  wet-nurse  or  the  institution  of  weaning  becomes 
necessary. 

In  the  dietetic  treatment  of  artificially  fed  infants  with  chronic  intes- 
tinal indigestion,  the  first  thing  required  is  a  very  careful  survey  of  the 
previous  history  in  the  effort  to  determine  what  element  of  the  food,  or 
fault  in  the  preparation,  has  originally  produced  the  disease,  or  has  main- 
tained it.  The  minutest  details  should  be  ascertained,  and  long-con- 
tinued, persistent  study  may  be  necessary.  Not  only  the  character  of  the 
food  must  be  considered,  and  the  degree  of  digestion  of  this,  especially  by 
an  examination  of  the  stools,  but  the  quantity  given,  the  intervals  of 
feeding,  the  rapidity  of  taking  nourishment,  the  amount  of  dilution  or 
concentration,  and  many  other  circumstances.  If  active  symptoms  are 
present,  dietetic  treatment  may  well  begin  with  a  moderate  starvation  for 
24  hours  or  longer.  For  this  purpose  some  thin  cereal  decoction  such  as 
barley  water  or  arrowroot  water,  is  generally  of  service.  After  this,  some 
form  of  diet  of  weak  strength  must  be  selected  until  better  digestive 
conditions  are  established,  and  a  more  permanent  food-supply  of  a 
satisfactory  character  can  be  tolerated.  Here  there  is  a  large  choice, 
depending  upon  what  the  dietetic  cause  and  the  character  of  the  symp- 
toms appear  to  have  been.  If  the  study  of  the  stools  (p.  731)  shows  that 
the  fat  is  especially  difficult  of  digestion,  as  is  true  in  the  large  majority 
of  cases,  milk-mixtures  made  from  skimmed  milk  are  suitable,  or,  still 
better,  in  my  experience,  those  from  buttermilk.  The  degree  of  dilution 
will  depend  upon  the  tolerance  for  protein.  Inasmuch  as  the  caloric 
value  of  these  foods  is  low,  they  may  often  be  strengthened  by  the  addi- 
tion of  carbohydrate  in  some  form.  If  there  is  difficulty  in  the  digestion 
of  sugar,  as  shown,  for  instance,  by  acid  diarrhea,  with  irritation  of  the 
buttocks,  buttermilk  is  of  especial  value  on  account  of  its  low  sugar- 
content  (p.  147).  Casein-milk  in  some  of  its  forms  is  serviceable  for  the 
same  reason,  having  a  low  percentage  of  carbohydrate  present,  unless 
sugar  has  been  added  to  it  (p.  148).  Since  there  is  a  difference  in  the 
digestibility  of  the  sugars,  it  is  often  possible  to  fortify  the  food  by  the 
addition  of  saccharose;  or  of  a  dextrine-maltose  preparation  (p.  129)  in 
place  of  milk-sugar.  Often,  however,  maltose-preparations  will  increase 
the  frequency  of  the  diarrhea.  It  is  well  also  to  increase  the  alkalinity 
of  the  maltose-mixture  by  the  addition  of  bicarbonate  of  potash. 

In  very  many  conditions  the  addition  of  an  msoluble  carbohydrate 
such  as  a  thin  or  thick  cereal  decoction  is  of  great  advantage,  its  strength 
varying  with  the  case.  The  mode  of  action  of  this  ingredient  is  uncer- 
tain. The  starch  is  to  an  extent  digested  and  utilized,  and  to  an  extent 
also  acts  mechanically  as  a  protective  colloidal  substance.  Certainly 
many  infants  do  better  when  the  plain  water  used  as  a  diluent  in  the 
mixture  is  substituted  by  a  cereal  water.  The  employment  of  starch 
serves  a  purpose  not  attained  by  the  addition  of  soluble  carbohydrate. 
It  is  for  this  reason  that  the  use  of  the  various  malt-soups  is  often  more 
efficacious  than  the  addition  of  sugar  or  of  dextrine-maltose  preparations 


CHRONIC  INTESTINAL  INDIGESTION  769 

alone.  (See  Malt-soup,  p.  156.)  The  casein  of  the  food  is  less  frequently  a 
source  of  indigestion,  but  undoubtedly  can  produce  it,  especially  in 
the  early  months  of  life.  The  symptoms  are  indefinite,  but  often  consist 
in  flatulence,  colic,  constipation,  and  an  offensive  odor  to  the  stools; 
less  often  in  the  passing  of  casein-curds  (p.  131).  Under  such  conditions, 
whey  is  frequentty  a  valuable  remedy.  Its  caloric  value  is  low;  but  in 
spite  of  this  young  infants  will  frequently  thrive  on  it  for  a  time.  Its 
nutritional  value  may  be  increased  by  the  addition  of  small  amounts  of 
strong  cream,  when  no  fat-indigestion  is  present.  The  amount  of  casein 
added  in  this  waj^  is  inconsiderable.  In  some  cases  where  fat,  too,  is 
not  tolerated,  the  whey  should  be  made  of  skimmed  milk,  and  white  of 
egg  may  be  added  to  it,  and  sugar  also,  preferably  dextrine-maltose 
preparations,  if  found  desirable.  The  employment  of  a  malt-soup  is 
sometimes  useful  here,  inasmuch  as  it  contains  both  soluble  and  insoluble 
carbohydrate.  In  still  other  cases  the  digestibility  of  the  casein  of  the 
food  may  be  increased  by  peptonizing,  but  this  is  not  so  often  needed 
as  formerlj'  believed. 

In  many  instances  an  intolerance  for  any  form  of  milk  develops, 
usuall.y,  however,  onl}'  temporar}^,  and  some  other  kind  of  nourishment 
must  be  employed  for  a  time.  Here  the  cereal  gruels  and  albumen  water 
are  often  serviceable.  The  gruel  must,  however,  be  sufficientl}^  strong 
to  give  it  some  real  food-value. 

As  regards  all  these  methods  described,  it  is  to  be  remembered  that, 
as  a  rule,  they  are  to  be  looked  upon  as  temporary  procedures,  to  be  care- 
fully changed  when  the  digestive  disorder  has  been  abated.  It  is  equally 
necessary,  too,  to  make  our  first  effort  the  allaying  of  the  symptoms;  not 
the  increasing  of  the  weight  of  the  child.  So  long  as  the  strength  is 
maintained,  and  the  weight  remains  stationary  or  diminishes  but  little, 
the  effort  to  cause  a  gain  in  this  respect  should  be  deferred  until  the  other 
symptoms  are  sufficiently  relieved. 

Besides  the  ingredients  of  the  food,  its  dilution  and  its  frequency  of 
administration  must  be  considered.  Some  infants  do  better  on  a  diluted 
food ;  others  upon  smaller  amounts  of  a  more  concentrated  nourishment. 
Only  trial  can  show  which  is  to  l)e  preferred.  As  a  rule,  too,  it  is  better 
to  make  the  intervals  of  feeding  decidedly  longer  than  in  health.  A  3- 
hour  or  4-hour  interval  in  the  early  months  of  life  may  be  better  than 
one  of  2  or  2I2  hours.  Still  another  factor  is  of  importance,  namely  the 
mutual  influence  which  the  different  food-ingredients  exercise  upon  each 
other.  For  instance,  the  addition  of  a  high  carbohydrate-percentage 
may  make  both  the  protein  and  the  fat  more  digestible,  as  seen,  for 
instance,  when  malt-soup  is  employed ;  or  fat  may  be  tolerated  if  the  whey 
is  diminished  in  amount.     (See  pp.  49,  50,  129,  130.) 

The  method  of  changing  from  any  one  of  these  substitutions  men- 
tioned to  one  containing  the  usual  elements  in  more  normal  ratio  is  often 
a  difficult  matter  which  must  be  determined  for  the  individual  case.  Thus 
an  infant  taking  whey  may  have  this  fortified  by  egg-album(>n,  and 
later,  in  cases  of  casein-indigestion,  after  the  symptoms  have  been  re- 
lieved, by  the  gradual  addition  of  peptonized  milk;  or  if  fat-indigestion 
has  been  present  also,  first  of  skimmed  milk  and  then  of  whole  milk.  A 
baby  with  sugar-int()l(>rance  fed  upon  casein-milk  may  gradually  have 
increased  amounts  of  saccharose  or  maltose  added.  One  with  fat-indi- 
gestion, fe<l  upon  Imttermilk,  may  after  a  time  have  small  amounts  of 
cream  added.  Certain  practical  j)oints  in  the  method  of  preparation 
must  be  borne  in  mind  in  making  any  such  changes.  Thus.  Ix^fore  mixing 
•49 


770  THE  DISEASES  OF  CHILDREN 

cream  or  milk  with  whey,  the  latter  must  be  heated  sufficiently  to  de- 
stroy the  rennet,  or  the  casein  will  be  coagulated.  So,  too,  in  fortifying 
whey  with  cream,  the  fat-percentage  of  the  latter  must  be  considered  in 
order  to  obtain  the  result  desired.  It  will  be  readily  seen,  for  instance, 
that  using  a  cream  of,  say,  30  per  cent,  fat-strength,  the  addition  of  1 
part  of  this  in  30  parts  of  the  food  increases  the  fat  by  1  per  cent.,  but 
raises  the  percentage  of  casein  to  so  small  an  extent  that  this  may  be 
ignored  entirely.  Were  a  weaker  cream  used,  much  more  of  it  would  be 
required,  and  the  casein  might  be  increased  undesirably.  Milk  or  cream 
added  to  buttermilk  will  be  coagulated  by  the  acid  present,  and  the 
mixture  must  be  shaken  well  and  not  allowed  to  stand  an}'  length  of  time 
before  it  is  given. 

With  the  use  of  the  substitutes  for  milk-feeding  in  the  form  of  the  very 
numerous  proprietary  foods  on  the  market,  I  have  had  a  large  experi- 
ence in  cases  seen  in  the  practice  of  other  physicians.  My  belief  is 
that  little  if  anything  is  to  be  gained  by  their  employment  which  cannot 
be  obtained  by  some  of  the  methods  already  outlined,  and  the  lack  of 
sufficient  general  knowledge  of  their  composition  prevents  physicians, 
as  a  rule,  from  using  them  intelligently.  In  no  disease  is  the  study  of 
the  individual  of  greater  necessity  than  in  chronic  intestinal  indigestion, 
and  this  is  seldom  made  when  proprietary  foods  are  ordered.  It  is  only 
by  this  study  and  by  the  consideration  of  the  apparently  unimportant 
matters  that  success  can  be  obtained,  whatever  the  food  employed. 

Many  cases  are  encountered,  however,  in  which  no  change  of  diet 
made  appears  to  influence  in  the  slightest  the  general  condition  of  the 
child.  There  may  be  neither  vomiting  nor  diarrhea,  but  the  weight  re- 
mains stationary  or  gradually  diminishes.  The  infant  has,  in  fact, 
reached  the  condition  described  by  Finkelstein  as  "decomposition"  (p. 
698),  where  it  is  no  longer  able  to  benefit  by  any  artificial  food  given.  In 
such  cases  nothing  remains  but  to  obtain  a  wet-nurse  if  possible.  This 
often  avails  in  a  surprising  manner;  but  often,  too,  fails,  because  it  has 
been  deferred  too  long,  and  the  digestive  functions  have  finally  become 
unable  to  utilize  even  the  infant's  natural  food.  To  wait  for  such  a  con- 
dition to  develop  before  advising  wet-nursing  is  bad  management  on 
the  part  of  the  physician.  On  the  other  hand,  the  procuring  of  a  wet- 
nurse,  valuable  as  this  so  often  is,  can  by  no  means  be  regarded  as  a 
certain  cure  for  intestinal  indigestion,  even  before  the  serious  condition 
mentioned  has  been  reached.  In  many  instances,  particularly  where 
there  is  much  fat-indigestion  on  the  part  of  the  intestine,  or  where  vomit- 
ing shows  the  presence  of  a  complicating  gastric  indigestion,  undiluted 
average  human  milk  is  too  rich  for  the  earlier  part  of  the  treatment, 
although  it  may  be  the  best  food  later. 

In  this  connection  reference  must  be  made  to  the  attempted  treat- 
ment of  intestinal  indigestion  and  of  diarrhea  by  the  direct  modification 
of  the  bacterial  flora  of  the  intestine.  As  pointed  out  by  Kendall  and 
Smith ^  and  others,  there  is  a  group  of  bacilli  in  the  intestine  claimed  to 
be  causative  of  the  symptoms  seen,  the  nmltiplication  of  which  can  be 
checked  by  either  the  direct  administration  of  other  germs  which  inter- 
fere with  their  growth,  or  by  the  giving  of  food  which  contains  or  favors 
the  increase  of  the  bacteria  desired.  The  Bulgarian  bacillus  and  other 
lactic  acid  organisms  are  especially  to  be  mentioned  here,  their  presence 
inhibiting  the  development  of  the  dangerous  proteolytic  bacteria.  Con- 
sequently, the  employment  of  buttermilk  which  has  not  been  heated 

'  Boston  Med.  and  Surg.  Jour.,  1911,  CLVII,  .306. 


CHRONIC  INTESTINAL  INDIGESTION  111 

after  it  was  made,  or  of  other  milk  containing  the  organisms  mentioned, 
or  the  direct  administration  of  cultures  of  these  germs,  is  curative  to  a 
disturbed  intestinal  digestion  in  a  number  of  cases.  This  view  has  found 
acceptance  in  many  quarters,  and  good  results  have  repeatedly  been 
reported.  It  is  impossible  as  yet  to  determine  the  true  value  of  the 
method,  or  to  know  to  what  degree  the  supposedly  harmful  germs  are 
directly  injurious,  or  to  what  degree  they  are  a  secondary  accompani- 
ment of  the  disorder. 

B.  Chronic  Intestinal  Indigestion  in  Older  CfflLDREN 

This  exceedingly  common  affection  in  children  past  the  period  of 
infancy  may  manifest  itself  in  typical  form,  or  may  give  rise  to  symp- 
toms which  are  very  confusing.  Disturbance  of  the  stomach  may  be 
combined  with  it. 

Etiology. — A  very  frequent  cause  is  persistence  with  the  ingestion 
of  carbohydrates  in  large  amount.  Any  starchy  food  may  give  trouble, 
but  potato  is  one  of  those  most  liable  to  do  so.  In  other  cases  too  long  a 
continuance  of  milk  as  the  chief  article  of  diet  may  bring  it  about.  The 
giving  of  candies  and  other  sweets;  allowing  the  child  to  eat  when  it 
pleases  between  meals;  in  some  cases  an  excess  of  fat  in  the  food;  and 
swallowing  without  sufficient  mastication  are  among  other  dietetic  in- 
fluences. Nourishment  of  any  sort  which  is  poorly  prepared  or  of  an 
indigestible  nature  is  likewise  a  cause.  The  disease  is  consequently 
conamon  in  children  who  receive  food  from  the  family  table  at  too  early 
an  age.  An  alteration  of  the  bacterial  flora  of  the  intestine  was  empha- 
sized by  Herter^  (see  p.  533)  as  the  cause  in  a  certain  class  of  cases;  the 
bacillus  bifidus,  bacillus  infantilis,  and  coccal  forms  characteristic  of  in- 
fancy persisting,  and  the  bacillus  coli  and  bacillus  lactis  aerogenes, 
which  should  normally  be  present  at  this  age,  being  absent  from  the 
feces.  Apart  from  this,  any  debilitated  condition  of  health  predis- 
poses. Consequently  the  disease  frequently  follows  some  acute  diar- 
rheal disturbance,  or  is  associated  with  rachitis,  or  develops  after  some 
exhausting,  acute  disorder,  and  is  one  of  the  conditions  often  occurring 
in  neurotic  children. 

The  majority  of  cases  come  under  observation  between  the  ages  of  3 
and  10  3'ears,  although  the  disease  has  not  uncommonly  begun  in  the 
2d  year  of  Hfe.     The  social  position  is  without  influence. 

Pathological  Anatomy.- — As  in  infancy,  the  disease  in  a  strict 
sens(;  is  a  functional  disturbance,  no  lesions  of  the  intestine  being  present, 
or  being  limited  perhaps  to  injection  and  redness  of  the  mucous  mem- 
brane and  an  increased  secretion  of  mucus.  Both  the  small  and  large 
intestine  are  commonly  much  dilated. 

Symptoms. — In  well-developed  typical  cases,  the  symptoms  are 
very  ciuuact eristic.  They  are  those  rather  of  cluonic  t<)X(>mia  tiian  of 
local  intestinal  (listurl)ance.  TIkm-c  isa  very  (U'('id(>(l  lossof  fh*sli,  the  limbs 
esjx'cially  being  tliin  and  the  child  having  a  delicate  appearance,  with  an 
anenii(!  or  sallow  complexion,  dai'k  rings  or  pufliness  under  the  eyes,  and 
perhaps  a  slightly  yellow  tint  to  the  sclera\  The  pallor  is  sometinu's  ic- 
placed  for  a  time  l)y  a  red  flush  of  the  cheeks,  and  on  other  occasions 
shows  a  great  temporary  increase,  as  though  the  child  were  faint  or 
nauseated.  The  appetite  is  variable  and  capricious  and  generally  very 
poor,  althougii  in  some  instances  excessive.     Eructation  of  gas  is  com- 

'  On  Iiif;iiitilistn  from  ("liioiiic  Iiitcstinal  Infcctimi,   l'.»()S. 


772  THE  DISEASES  OF  CHILDREN 

mon,  as  is  its  passage  from  the  bowel,  and  the  abdomen  is  usually  much 
distended  and  tympanitic.  This  abdominal  distention  is  one  of  the  most 
characteristic  symptoms.  Nausea  and  vomiting  maj-  occasionally 
occur  if  the  stomach  shares  in  the  dyspeptic  condition,  but  in  some  in- 
stances vomiting  and  headache  appear  to  depend  upon  intestinal  toxemia. 
The  tongue  is  pale,  flabby  and  perhaps  tooth-marked;  sometimes 
coated;  sometimes  exhibiting  enlarged  papilla.  It  has  seemed  to  me  that 
the  geographical  tongue  (p.  667)  is  particularly  liable  to  be  found  in  this 
disease,  although  of  course  not  confined  to  it.  The  odor  of  the  breath 
may  be  offensive,  but  this  and  the  condition  of  the  mouth  and  tongue 
depend  largel}^  upon  the  gastric  disturbances  frequently  associated.  The 
bowels  are  usually  constipated,  or  constipation  may  alternate  with 
attacks  of  diarrhea.  The  color  of  the  stools  is  generally  pale  and  some- 
times nearly  white;  at  other  times  brownish.  They  are  frequently 
offensive  in  odor,  contain  undigested  food,  and  when  loose  are  often 
frothy  in  appearance.  Mucus  is  passed  at  times,  perhaps  in  large  amount. 
The  mucus  is  mixed  with  the  stool  when  this  is  loose,  or  coats  it  when 
formed.  The  element  of  abdominal  pain  is  very  variable,  being  somewhat 
colicky  and  paroxysmal,  and  frequently  accompanying  an  evacuation  of 
mucus.  Oftenest  it  is  slight,  and  sometimes  is  no  more  than  a  sensation 
of  abdominal  discomfort.  The  urine  is  not  characteristic.  At  times 
it  may  show  the  presence  of  indican  in  considerable  amount,  or  of 
other  bodies  denoting  indigestion.  The  general  health  suffers  and  the 
children  develop  poorly  in  height  and  weight. 

The  nervous  symptoms  are  many  and  varied.  In  fact  they  are  often 
the  most  prominent  manifestations  of  the  disease,  and  may  readily  lead 
to  a  mistaken  diagnosis.  Although  the  child  is  mentally  unaffected  and 
often  very  bright  and  even  precocious,  he  is  irritable,  hypochondriacal, 
languid,  and  easily  tired.  The  hands  and  feet  are  cold,  and  the  skin 
perspires  readily.  Sleep  is  nearly  always  restless  and  tossing,  with  fre- 
quent grinding  of  the  teeth.  Outcries  and  dreaming,  and  not  infrequently 
night-terrors  and  somnam])ulism  are  observed.  Wakefulness  is  not  an 
uncommon  symptom.  In  some  cases  there  is  stupor,  or  even  tetany  or 
convulsions.  Shortness  of  breath  is  sometimes  witnessed,  or  the  respira- 
tion may  occasionally  be  sighing  in  character.  In  other  instances  asth- 
matic symptoms  of  digestive  origin  may  be  present.  There  is  usually 
little  or  no  fever,  or  perhaps  the  constant  presence  of  an  elevation  of  tem- 
perature of  less  than,  or  even  slightly  over,  100°F.  (37.8°C.) ;  except  during 
the  occurrence  of  exacerbations  when  the  temperature  rises  considerably. 
The  pallor  of  the  skin  does  not  necessarily  depend  upon  an  actual  anemia. 
In  some  cases  the  skin  is  unnaturally  chy;  in  others  there  is  an  urticarial 
or  erythematous  eruption. 

The  group  of  symptoms  as  described  is  not  seen  in  its  entirety  in 
every  instance.  In  the  milder  cases,  or  those  which  have  lasted  but  a 
short  time,  the  disease  is  rather  a  series  of  acute  attacks  of  moderate 
severity,  with  intervals  of  comparative  health,  and  with  but  httle  dis- 
turbance of  the  general  condition.  In  others  symptoms  of  a  severe  type, 
with  a  degree  of  wasting  suggestive  of  pulmonary  tuberculosis,  are  at- 
tended at  times  by  the  passing  from  the  bowel  of  unusually  large  amounts 
of  mucus.  To  this  complex  of  symptoms  the  title  "Mucous  Disease" 
was  applied  by  Eustace  Smith.  ^  Another  form  of  the  affection  was 
called  "Coeliac  Disease"  by  Gee. ^     Here  the  predominant  symptoms  are 

1  "Wasting  Diseases  of  Infants  and  Children,"  2d  Amer.  Ed.,  156. 

2  St.  Barthol.  Hosp.  Rep.,  1888,  XXIV,  17. 


CHRONIC  INTESTINAL  INDIGESTION  773 

the  pasty,  white,  offensive,  and  poorly  digested  stools,  containing  an 
excess  of  fat  and  moderately  increased  in  frequency  and  especially  in 
size;  wasting;  debility;  and  often  retardation  of  growth.  Well-marked 
cases  of  this  type  have  been  denominated  by  Herter^  "Intestinal  in- 
fantilism." (See  Vol.  II,  p.  533.)  These  alwaj's  exhibit  evidences^^'of 
unusual  putrefaction  of  the  intestinal  contents  and  the  presence  of  large 
numbers  of  the  bacillus  bifidus  and  the  bacillus  infantihs  in  the  feces, 
instead  of  the  usual  bacillus  coli.  There  is  not  only  a  decomposition  of 
protein,  but  a  failure  to  absorb  the  carbohydrate  and  fat,  together  with  a 
loss  of  calcium  and  magnesium  in  the  form  of  soaps. 

Course  and  Prognosis.^ — Children  with  chronic  intestinal  indigestion 
are  usually  slow  in  recovery,  even  under  treatment,  the  disease  often  last- 
ing for  years.  There  is  a  tendency  to  acute  exacerbations  of  gastric  or 
intestinal  disturbance.  These  occur  at  irregular  and  often  frequent  in- 
tervals, are  provoked  by  slight  and  often  undiscoverable  causes,  and  are 
characterized  by  nausea,  vomiting,  diarrhea,  slight  fever,  increased  loss 
of  appetite  and  a  greater  manifestation  of  nervous  sj^mptoms.  In  the 
intervals  between  the  attacks  the  evidences  of  indigestion  ma}'  at  first 
be  very  slight,  or  in  the  mildest  cases  wholly  absent;  but  it  is  not  long 
before  there  is  a  fuller  development  and  increase  in  the  severitj'-  of  the 
symptoms  until  some  signs  of  the  disorder  are  constant^  present. 
The  course  of  the  disease  at  best  is  chronic,  its  length  depending  upon 
the  nature  of  the  cause,  the  severity  of  the  symptoms,  the  duration  be- 
fore the  treatment  was  commenced,  and  the  patience  and  faithfulness 
with  which  this  is  carried  out  by  the  parents.  Onl}'-  in  mild  cases,  or  in 
those  severer  ones  in  which  the  errors  in  diet  and  hygiene  have  been  very 
evident  and  consequently  easily  corrected,  can  we  hope  for  more  rapid 
improvement.  In  the  milder  cases  there  is,  it  is  true,  a  certain  degree  of 
natural  tendency  to  recover  when  puberty  is  reached;  but  this  can  in  no 
way  be  depended  upon,  and,  as  a  rule,  there  is  little  hkelihood  of  sponta- 
neous cessation  in  untreated  cases.  The  prognosis  of  those  under  treat- 
ment is  on  the  whole  good,  except  in  the  instances  where  little  can  be 
found  wrong  with  the  h3'giene  and  diet,  and  where  there  seems  to  be  a 
constitutional,  or  an  early  acquired  and  finally  firmly  seated,  lack  of  func- 
tional intestinal  power.  There  is  always,  too,  the  danger  in  this  disease 
that  the  impaired  general  health  may  diminish  the  power  of  resistance  to 
some  intercurrent  affection  such  as  bronchopneumonia. 

Diagnosis. — The  tympanitic  condition  in  intestinal  indigestion 
may  he  so  great  that  I  have  known  cases  erroneously  diagnosed  as  idio- 
pathic dilatation  of  the  colon,  and  have  been  able  to  prevent  dangerous 
and  unnecessary  operative  interference.  The  two  conditions  are  quite 
distinct  in  their  history  and  symptoms.  The  nervous  symptoms  may 
be  confusing  if  the  condition  of  the  digestion  is  not  carefully  studied,  but 
with  this  exception  the  diagnosis  is  usually  not  difficult.  The  slight 
cough  which  may  accompany  the  wasting  can  suggest  pulmonary  tuber- 
culosis, but  examination  of  the  lungs  fails  to  reveal  any  anomaly.  A 
negative  von  Pirquct  reaction  would  be  of  value.  TubiTculous  jx'ritonitis 
exhibits  tenderness  and  either  fluid  or  some  evidence  of  deposit  in  or 
thickening  of  the  alxlominal  walls.  The  presence  of  intestinal  worms 
may  produce  grinding  of  the  teeth,  abdominal  pain,  {hsturi)e(l  \i\vvp  and 
other  nervous  symptoms;  but  the  administration  of  a  vermifug(>  will 
reveal  the  cause  and  clear  up  the  tliagnosis.  Convulsions  in  chihlliodd 
are  often  considered  to  be  a  manifestation  of  epilepsy,  when  they  really 

'  Loc.  cit. 


774  THE  DISEASES  OF  CHILDREN 

depend  solely  upon  chronic  intestinal  indigestion.  To  complete  the 
diagnosis  of  indigestion  a  careful  and  even  a  microscopical  examination 
of  the  stools  may  be  required,  demonstrating  that  the  food  is  passing 
in  an  undigested  form  and  showing  the  exact  nature  of  this. 

Treatment.^ — Dietetic  treatment  occupies  the  primary  place.  First 
in  this  connection  is  to  be  considered  the  manner  of  eating.  Attention 
must  be  paid  to  the  condition  of  the  teeth;  since  carious  teeth,  especially 
if  painful,  may  render  proper  mastication  impossible.  Apart  from  this, 
there  is  a  natural  disposition  in  early  childhood  to  eat  with  little  mastica- 
tion, and  this  readily  becomes  a  fixed  habit  unless  carefully  guarded  agi'inst. 
The  life  must  be  so  ordered  that  there  may  be  suflicient  time  to  eat  slowly. 
Partaking  of  a  hurried  breakfast  in  order  not  to  be  late  for  school  is  a 
common  cause  of  chronic  indigestion.  The  haste  of  the  luncheon  at 
school  is  often  as  harmful  as  the  improper  nature  of  the  articles  frequently 
eaten  at  that  time.  Not  too  large  an  amount  of  food  must  be  ingested  at 
any  meal.  On  the  other  hand,  since  the  appetite  is  often  poor,  meals  maj'' 
need  to  be  more  frequent  than  in  health  in  order  to  obtain  the  taking  of  a 
sufficient  amount  of  nourishment.  Meals  should  be  at  regular  intervals 
and  no  food  at  all  given  between  them. 

Those  articles  must  be  excluded  from  the  dietary  which  are  most 
liable  to  cause  indigestion,  or  which  have  been  found  to  do  so  in  the  indi- 
vidual case.  This  individuality  is  an  important  matter;  what  agrees 
with  one  child  perhaps  disagreeing  with  the  next.  In  general,  however, 
as  already  stated,  the  food  most  frequently  the  cause  of  the  symptoms 
consists  of  the  carbohydrates  and  especially  the  starches,  and  next  to 
these  in  importance  fat  in  any  form.  Consequently,  in  bad  cases  it 
would  be  best  to  eliminate  starch  and  fat  almost  entirely  for  a  time, 
until  improvement  is  well  established,  the  child  eating  only  meat,  skimmed 
milk,  buttermilk,  beef-juice,  broths,  oysters,  white  of  egg,  green  vege- 
tables and  similar  substances.  Such  vegetables  may  be  chosen  as  lettuce, 
spinach,  asparagus,  vegetable-marrow,'i  stewed  celery,  and  tomatoes,  the 
carbohydrate  content  of  which  runs  from  2  to  3  per  cent.  (Joslin).^  As 
it  is  difficult  to  institute  such  a  restricted  diet  in  children,  and  as  the 
milder  cases  do  not  require  it,  we  may  generally  obtain  good  results  by 
merely  limiting  the  amount  of  starch  very  greatly.  Potatoes  should  not 
be  given  at  all,  since  their  digestibility  is  certainly  less  than  that  of  some 
other  amylaceous  foods.  As  little  bread  should  be  used  as  possible.  It 
should  be  stale,  thoroughly  toasted,  or  in  the  form  of  zwieback,  only  a 
small  piece  being  given  with  the  meal.  Some  unsweetened  commercial 
biscuit,  such  as  water  crackers,  oyster  crackers,  and  the  like,  taken  in 
small  amount,  may  replace  bread  at  times.  Among  other  foods  which 
must  be  used  with  caution  on  account  of  their  carbohydrate  content,  are 
white  and  lima  beans,  peas,  carrots,  corn,  beets  and  parsnips.  Cereal 
porridges  must  likewise  be  partaken  of  in  very  small  amounts,  if  at 
all,  and  such  as  oat-meal  or  those  of  whole  wheat  avoided,  on  account 
of  their  more  irritating  character.  Arrowroot,  rice  and  farina  are  to  be 
preferred.  Even  the  soluble  carbohydrates,  the  various  sugars,  maintain 
the  state  of  indigestion.  This  is  particularly  true  of  candies,  jellies, 
jams,  and  preserved  fruit.  Consequently,  these  are  to  be  avoided  en- 
tirely, or  very  small  amounts  of  cane-sugar  employed  as  a  necessary  sweet- 
ening, and  this  only  if  the  child  will  not  do  without  it.  Sometimes  sac- 
charin may  be  substituted  for  sweetening  purposes.  Most  fruits  come  in 
the  same  category  as  sugars,  and  should  not  be  given  until  improvement 
1  The  Treatment  of  Diabetes,  191(^,  401. 


CHRONIC  INTESTINAL  INDIGESTION  775 

is  distinct!}'  under  way.  Baked  apples,  prune-juice  and  orange-juice  are, 
perhaps,  the  best.  What  is  said  of  other  sugar-containing  foods  is  true 
also  of  the  various  dextrinized  breakfast  cereals  on  the  market.  Their 
administration  should  be  deferred  at  the  beginning,  and  then  commenced 
as  an  intermediate  step  in  the  return  to  ordinary  cereal  foods. 

Another  very  powerful  factor  in  producing  indigestion  is  fat,  and  in 
some  instances  it  is  this,  rather  than  the  starch,  which  is  causing  trouble. 
Consequently,  all  fats,  including  butter  and  the  yolk  of  egg,  must  be 
prohibited  in  such  cases,  the  fat  removed  from  any  meat  given,  and 
skimmed  milk  or  buttermilk  used  in  place  of  whole  milk.  All  fried  food 
and  pastry  are  to  be  rigorously  excluded.  Cocoa  is  sometimes  very  well 
tolerated;  sometimes  not. 

A  diet  rich  in  protein  is  often  one  of  the  best.  Broiled  or  roast  beef, 
mutton,  or  chicken,  is  usually  well  borne,  in  amount  depending  upon  the 
age  of  the  child.  For  young  children  it  should  be  scraped  or  minced 
finely,  and  this  may  be  necessary  for  older  ones  as  well,  if  thorough  masti- 
cation cannot  be  succesfully  insisted  upon.  Beef -juice  is  useful,  although 
not  very  nourishing  unless  in  larger  amount  than  can  be  given  with  success 
in  most  cases.  Broth  with  the  meat-fibre  retained  in  it  in  finely  divided 
form  is  serviceable,  but  thickening  with  any  starchy  addition  must  be 
avoided  early  in  the  case.  The  fat  should  be  thoroughly  removed  from 
the  broth  before  this  is  given.  The  best  of  the  proteid  foods  in  most  of 
these  cases  undoubtedly  is  milk  free  from  fat,  and  this  should  form  a 
large  part  of  the  diet.  If  there  is  difficulty  in  digesting  the  casein,  the 
milk  should  be  partially  peptonized;  or  even  completely  so,  if  the  child 
can  be  induced  to  take  it  in  this  way.  Buttermilk  is  sometimes  very 
serviceable.  Eggs  form  a  valuable  food  for  many  children,  but  are  not 
well  borne  by  many  others.  It  is  rarely  advisable  to  allow  them  every 
day,  and  at  first  only  the  white  of  the  egg  should  be  given.  Boiled  or 
baked  fish  is  often  useful,  and  oysters,  raw  or  very  sHghtly  stewed,  are 
very  well  digested  by  some  patients.  Sometimes  one  of  the  high-protein 
proprietary  foods  on  the  market  may  be  employed.     (See  p.  1(55.) 

Useful  vegetables  in  many  instances  are  string  beans  mashed  through 
a  colander,  spinach,  squash,  stewed  celery,  stewed  salsify,  asparagus 
tips  and  lettuce.  The  time  of  beginning  these  varies  with  the  age  of 
the  child  and  with  the  necessity  of  finding  some  food  to  take  the  place  of 
the  articles  which  are  forbidden.  When  possible,  their  use  should  be 
deferred  for  some  months  in  cases  at  all  severe.  Young  cauliflower, 
Brussel  sprouts  and  onions  are  theoretically  valuable  members  of  this 
class  of  vegetables,  but  their  strong  odor  and  taste  often  make  them 
undesirable. 

Last  of  all,  when  other  foods  are  found  to  be  well  tolerated  and 
conval(^s(•ence  is  well  established,  but  even  then  only  after  a  {)erit)d  of 
some;  months,  a  very  careful  return  to  the  ordinary  use  of  starch  may  be 
atteinpted,  allowing  only  small  ([uantities  at  first.  It  may  be  that  potato 
cannot 'be  given  at  all  for  a  long  linu;.  Months,  or  a  year  or  more,  may 
be  HMiuirccl  to  elTect  a  cure.  In  the  event  of  a  relapse  occurring,  the 
diet  should  at  once  be  reduced  greatly,  employing  the  simple  regimen 
with  which  the  treatment  was  commenced.  An  absolute  skimmed- 
milk  diet  for  a  short  time  is  often  successful  on  these  occasions. 

A  diet-list  for  milder  cases  of  chronic  intestinal  indigestion,  in  which 
a  certain  amount  of  starch  is  permitted  and  in  which  whole  milk  and  eggs 
are  tolerated,  would  read  sonunvhat  ;is  i'olhtws,  varying,  of  course,  with* 
the  age  and  the  individual  rcfiuircnients: 


776  THE  DISEASES  OF  CHILDREN 

Breakfast — 7  a.m.:  ]\Iilk  with  lime  water;  soft  boiled  egg  or  mutton- 
chop,  fish  or  cold  beef;  a  slice  of  stale  bread  without  butter,  or  zwieback, 
water-crackers  or  similar  unsweetened  biscuit. 

Lunch — 11  A.M.:  Milk,  or  broth  free  from  fat. 

Dinner — 2  p.m.:  Roast  or  In-oiled  chicken,  beef  or  mutton  free  from 
fat,  or  sweetbread;  spinach,  string  beans,  stewed  celery,  stewed  salsify 
or  asparagus  tips;  bread  or  crackers  as  at  breakfast.  For  dessert  junket, 
baked  apple,  or  a  gelatin  food. 

Supper — 6  to  7  p.m.:  Milk,  buttermilk,  or  broth;  with  bread  as  at 
breakfast. 

Hygienic  treatment  is  also  of  importance.  A  daily  cool  morning  sponge 
is  conducive  to  improvement  of  the  general  health.  There  must  be 
sufficient  sleep  in  a  well  ventilated,^ cool  room.  The  mid-morning  nap 
should  be  continued  as  long  as  the  child  can  be  induced  to  take  it.  If 
this  period  is  past,  at  least  an  hour's  rest,  recumbent,  in  the  middle  of 
the  day,  preferably  before  the  mid-day  meal,  is  very  useful  in  many  cases. 
Life  out  of  doors  is  important.  Whether  or  not  the  child  shall  attend 
school  must  be  determined  for  each  case  individually.  Against  the 
confinement  in  school  is  to  be  balanced  the  disadvantage  of  lack  of  oc- 
cupation and  of  companionship  which  staying  at  home  often  entails. 
Fatigue,  either  mental  or  physical,  is  to  be  carefully  avoided.  Clothing 
must  be  regulated  to  provide  sufficient  warmth  without  occasioning  too 
free  perspiration  on  exercise.  Bare  legs  are  not  to  be  allowed,  since  the 
chilhng  which  is  liable  to  occur  predisposes  to  interference  with  diges- 
tion. Massage  is  serviceable  for  patients  too  debilitated  to  take  suffi- 
cient exercise.     Change  of  chmate  is  often  most  beneficial. 

Medicinal  treatment  is  largely  a  secondary  consideration.  The  over- 
coming of  the  constipation,  which  is  such  a  common  symptom,  is  im- 
portant. In  bad  cases  the  nightly  injection  of  cotton-seed  oil  may  be  of 
service.  (See  Constipation,  p.  757.)  Very  frequently  the  diet  may 
be  successfully  selected  to  overcome  the  constipation,  bearing  in  mind, 
however,  that  many  of  the  laxative  foods  are  more  or  less  irritating  to  the 
bowels.  As  a  rule  enemata  are  not  efficient,  as  they  operate  only  upon 
the  rectum,  and  a  drug  is  required  which  affects  the  whole  intestinal 
tract.  In  addition  to  such  laxatives  as  cascara,  senna,  phenolphthalein, 
and  the  like,  it  is  well  to  obtain  a  thorough  purging  at  intervals  of  from 
5  to  7  days,  employing  calomel  or  citrate  of  magnesia  for  this  purpose. 
Where  there  is  much  secretion  of  mucus  from  the  bowel,  saline  douching 
is  sometimes  of  service,  but  this  practice  should  not  be  continuous  as 
it  sometimes  maintains  the  symptom  which  it  is  intended  to  cure.  The 
administration  of  a  good  malt-extract  appears  to  aid  the  digestion  of 
starch.  One  should  be  selected  known  to  contain  a  large  percentage  of 
diastase,  there  being  a  great  difference  among  them  in  this  respect. 

In  general,  so  far  as  the  administration  of  drugs  goes,  I  have  had  the 
best  results  with  the  combination  of  an  alkah  with  a  bitter  tonic.  For 
this  purpose,  bicarbonate  of  soda  may  be  given  with  tincture  of  nux 
vomica,  compound  tincture  of  gentian  and  an  aromatic  water,  adminis- 
tered 10  to  20  minutes  before  meals.  In  other  cases,  a  small  amount  of 
sulphate  of  magnesia,  cascara,  or  syrup  of  rhubarb  may  be  added,  or  a 
laxative  mineral  water  employed,  if  constipation  is  a  troublesome  symp- 
tom. Cod-liver  oil,  although  theoretically  an  excellent  remedy  to  improve 
the  general  health,  is  often  contra-indicated,  especially  early  in  the  disease, 
on  account  of  its  tendency  to  increase  indigestion  in  many  instances. 
The  same  remark  applies  to  the  use  of  iron  given  for  the  anemia,  since 


DILATATION  OF  THE  COLON  777 

until  convalescence  is  established  the  iron  may  increase  the  digestive 
trouble  and  the  constipation. 

Last  of  all,  the  importance  of  persistence  in  the  treatment  must  be 
again  emphasized.  Unless  this  is  maintained,  and  especially  unless  the 
dietetic  treatment  is  rigorously  followed  for  months,  an  improvement 
which  has  seemed  very  decided,  and  even  a  cure  which  has  seemed  com- 
plete, will  inevitably  be  followed  by  relapse. 

DILATATION  OF  THE  COLON 

This  condition  may  be  divided  into:  (A)  Congenital  Idiopathic  Dila- 
tation (Megacolon  congenitum) ;  and  (B)  Secondary  Dilatation. 

(A)  Idiopathic  Dilatation  of  the  Colon. — ^The  nature  of  the  disease 
is  not  well  understood.  Writing  in  1899  and  reporting  an  instance  of  the 
affection^  I  was  able  to  collect  but  23  previously  published  cases  which 
could  be  accepted  with  reasonable  certainty;  although  there  were  a 
decidedly  larger  number  of  others  probably  incorrectly^  so  named.  The 
i  number  of  reported  cases  has  increased  greatly  since  that  time.  Finney- 
in  a  very  careful  paper  collected  206  published  articles  upon  the  subject 
up  to  that  date;  PateP  collected  223  cases,  200  of  which  had  come  to 
autopsy  or  been  operated  upon;  and  since  then  Porter  and  Weeks'*  have 
found  over  100  more.  The  disease  was  first  described  with  care  by 
Hirschsprung^  and  is  often  called  by  his  name,  but  a  number  of  well- 
characterized  instances  had  been  published  earlier,  as,  for  example, 
those  by  Henoch,*^  Peacock,'^  Hughes*  and  still  earher  cases  go  back  to 
Parry 9  and  Billard.i" 

Etiology.^The  disease  is  3  times  more  frequent  in  boys.  A  very 
probable  theory  explains  the  condition,  although  in  a  general  way,  as 
dependent  upon  a  congenital  tendency  for  the  colon  to  dilate.  The  cause 
of  this  is  of  unknown  nature,  and  the  explanation  leaves  the  matter  far 
from  clear.  It  has  been  supposed  by  some  to  be  neuro-muscular; 
perhaps  a  paralysis  of  a  region  of  the  colon,  with  arrest  of  peristalsis; 
perhaps  a  spasm  producing  functional  obstruction.  Findings  at  autopsies 
do  not  confirm  this  view.  The  disease  does  not  depend  upon  general 
muscular  atony,  since  the  children  are  healthy  in  other  respects.  The 
relatively  great  length  of  the  colon  and  especially  of  the  sigmoid  flexure 
in  infants,  to  which  attention  was  called  parti cularl}'^  by  Jacobi^^  un- 
doubtedly aids  in  producing  dilatation,  but  cannot  alone  account  for 
it,  or  the  disease  would  be  much  more  common  than  it  is.  Whether  the 
hypertrophy  of  the  wall  is  the  cause,  the  attendant,  or  the  result  of  the 
dilatation  is  uncertain.  Unquestionably  in  some  fatal  cases  in  the  new 
born  l)oth  (Hlatation  and  hypertrophy  have  been  found,  so  that  in  these 
instances  at  least  the  hypertrophy  was  not  a  secondary  concHtion. 
Generally,  however,  the  latter  appears  to  be  secondary  to  the  cUlatation. 

1  Amer.  Jour.  Med.  Sci.,  1899,  Sept. 
^  Surg.,  Gynoc.  and  Ohstet.,  1908,  VI,  624. 
3  Toulouse  lued.,  1910,  XII,  282. 
*  Amer.  Jour.  Dis.  (ndld.,  1915,  IX,  2S3. 
sjahrb.  f.  Kinderlu-ilk.,  18S8,  XXVII,  1. 
«  lieitriige  z.  Kiiiderli.,  1801,  VIA. 
'Trans.  Patli.  Soe.  of  London,  1872,  XXIll.  104. 
8  Trans.  Path.  Sue.  of  I'liila.,  1887,  Xlll,  40. 

"  Collcetions  from  the  Unpublished  JNIed.  Writings  of  the  late  C.  H.  Parrj-,  1825, 
II,  380.     Ref.  Finney. 

'"  Die  Krankh.  d.  Neugeborenen  u.  Sauglinge,  1829-37,  330.     Ref.  Finiiev. 
•1  Amer.  Jour.  Ob.stet.,  1809-70,  II,  90. 


778 


THE  DISEASES  OF  CHILDREN 


That  the  clihitation  and  hypertrophy  are  both  dependent  upon  a  con- 
striction in  some  lower  portion  of  the  gut  was  maintained  by  Treves.^ 
Careful  search  at  autopsies  has,  however,  failed  to  reveal  any  such  con- 
striction in  the  majority  of  cases;  and  those  where  it  is  found  belong  more 
properly  to  the  category  of  Secondary  Dilatation  of  the  Colon. 

Pathological  Anatomy. — The  colon  may  be  involved  throughout,  or 
oftener  the  sigmoid  flexure  alone.  Exceptionally  the  rectum  and  the  lower 
portion  of  the  ileum  share  in  the  dilatation,  which  is  sometimes  enormous 

(Figs.  254  and  255).  Thickening  of  the  in- 
testinal wall,  especially  of  the  muscular  layer, 
is  present  in  nearly  all  instances.  The 
mesocolon  may  be  longer  or  shorter  than 
normal,  and  is  sometimes  thickened.  In 
cases  of  somewhat  long  standing  inflammatory 
changes  and  even  ulceration  develop. 

Symptoms. — These  consist  of  great  dilata- 
tion of  the  colon  and  of  obstinate  constipa- 
tion. In  the  severer  cases  the  s>Tnptoms, 
or  at  any  rate  the  constipation,  appear  in 
the  first  few  days  of  life.  In  others,  the 
congenital  tendency  to  dilate  is  probably 
present,  but,  owing  to  the  greater  resisting 
power  the  evidences  of  the  disease  come  on 
more  slowly,  although  still  generally  in  the 
first  3  months  of  life,  constipation  being  the 
first  and  dilatation  developing  later  and 
increasing  gradually.  Occasionally  dilatation 
has  not  appeared  until  the  age  of  a  year. 
The  constipation  is  of  a  most  obstinate 
nature,  1  to  2  weeks  or  more  sometimes  passing 
without  a  movement.  Then  under  treatment 
an  evacuation  of  enormous  size  takes  place. 
The  stools  are  rarely  scybalous  and  in  fact 
may  be  at  times  diarrheal,  the  difficult}^  of 
evacuation  depending  not  on  any  character- 
istic of  the  fecal  matter,  but  on  lack  of 
power  to  expel  it.  The  degree  of  distention 
varies  with  the  case,  but  is  usually  very  great. 
In  a  child  of  2  years  and  11  months  under 
my  care,  the  girth  equalled  28  inches  (71.1  cm.) 
(Fig.  25G).  The  abdominal  distention  may  be 
relieved  to  a  considerable  extent  by  a  free 
evacuation  of  the  bowqls,  but  this  does  not 
follow  in  every  case.  The  health  is  liable  gradu- 
ally to  suffer  and  emaciation  to  develop,  but  this  does  not  occur  for 
several  years,  and  sometimes  the  condition  of  general  nutrition  is  but 
httle  affected.  Vomiting  is  uncommon,  and  there  is  little  pain.  Dysp- 
nea may  be  produced  by  the  pressure  against  the  diaphragm.  Peris- 
taltic waves  may  be  seen  in  the  colon  in  cases  not  too  far  adv'anced. 

(B)  Secondary  Dilatation  of  the  Colon. — The  etiology  of  this  con- 
dition varies  with  the  case.  In  some  instances  there  has  been  mechanical 
obstruction  due  to  a  stenosis  of  the  intestine  or  to  obstruction  of  some 

1  Lancet,  1898,  I,  276. 


Fig.  254. — Idiopathic  Dilata- 
tion OF  THE  Colon. 
Child  of  4  years,  patient  at 
the  Children's  Hospital  of  Phila- 
delphia. No  discomfort  in  the 
abdomen,  enlargement  always 
present,  constipation,  maxi- 
mum girth  2734  inches  (69.24 
cm.) .  Operation  deferred  as  un- 
warranted on  account  of  his  gen- 
eral excellent  health. 


DILATATION  OF   THE  COLON 


779 


other  nature,  either  in  the  bowel  itself  or  from  without  as  bj'  the  pres- 
sure of  a  tumor  or  cyst.  In  other  cases  habitual  constipation  may 
finally  be  followed  by  distention  of  the  colon,  perhaps  as  a  result  of  a 
partial  kinking  of  the  bowel  through  the  weight  of  the  fecal  matter  con- 
tained. The  disease  due  to  this  cause  is,  however,  more  liable  to  occm*  in 
later  life.    An  atonic  state  of  the  colon  with  consecutive  dilatation  may 


'""  V 


\\<..  255. — Radioghm-h  OF  Idioi'a  .  iation  oi- the  Colon-. 

From  the  .sjuiu'  rase  lis  seen  in  Fig.  254,  after  ilie  iidministration  of  hariuni. 
greatly  distended  loop  of  colon  occupied  the  right  .side  of  tlie  alidonien. 


A  largo, 


follow  some  ticbililaliiig  disease.  Tt  is  of  common  occurreiu'c  in  rachitis, 
and  J  is  a  characteristic  symplom,  to  ;i  varying  degree,  of  severe  chronic 
intestinal  indigestion  and  of  tuiierculous  peritonitis. 

The  symptoms  of  secondary  dilatation  do  not'differ  materially  from 
those  characteristic  of  the  idiopntliic  variety.     The  distention  in  rachitis 


780 


THE  DISEASES  OF  CHILDREN 


is  not  so  great  as  in  instances  dependent  upon  other  causes  and  is  seldom 
productive  of  such  obstinate  constipation. 

Course  and  Prognosis  of  Dilatation  of  the  Colon. — The  prognosis 
of  congenital  idiopathic  dilatation  is  very  unfavorable.  Of  the  24  cases 
of  my  report  18  were  known  to  have  died  and  in  only  3  was  recovery 

recorded.  The  fate  of  the  others  was  un- 
known. In  59  cases  treated  medically,  col- 
lected by  Lowenstein,^  the  mortality  was  66 
per  cent. ;  while  in  44  operated  cases  it  was 
48  per  cent.  In  a  later  series  of  110  cases 
subjected  to  surgical  treatment,  collected  by 
Terry-  the  mortality  was  25  per  cent.  The 
patients  rarely  live  to  adult  life.  The  ma- 
jority die  before  the  age  of  5  years  of  in- 
creasing inanition  and  debihty,  or  some 
complication  as  bronchopneumonia,  cardiac 
failure,  peritonitis  from  perforation,  or 
chronic  intestinal  toxemia.  There  is  not 
infrequently  temporary  slight  improvement 
with  recurrent  exacerbations  of  the  condition. 
The  prognosis  of  the  secondary  dilatation 
following  stenosis  of  the  intestine  is  unfavor- 
able, inasmuch  as  operative  interference 
alone  can  effect  a  cure,  although  life  may 
continue  for  years  if  the  stenosis  is  not  too 
great.  That  of  dilatation  associated  with 
debilitated  health  is  uncertain  and  depends 
upon  the  severity  and  the  duration  of  the 
condition. 

Diagnosis.- — This  is  rather  of  the  form 
])resent  than  of  the  condition  itself,  which  is 
easily  recognizable.  In  idiopathic  dilatation 
there  is  an  absence  of  any  discoverable  ob- 
struction, or  evidence  of  previous  bad  health 
which  might  have  produced  intestinal  atony. 
The  cause  of  a  secondary  dilatation  may  be 
discovered  only  at  autopsy.  The  diagnosis 
has  often,  therefore,  an  element  of  doubt. 
Secondary  dilatation  dependent  upon  rickets, 
chronic  intestinal  indigestion,  or  other  debilitat- 
ing disease  is  associated  with  symptoms  which 
usually  make  the  recognition  of  the  cause  plain. 
From  acquired  obstruction  of  an  acute  nature 
the  diagnosis  of  dilatation  of  either  form  is 
easily  made,  based  especially  upon  the 
chronicity  of  the  course. 
Treatment. — This  depends,  to  some  extent,  upon  the  nature  of  the 
cause.  Cases  in  which  the  diagnosis  of  stenosis  can  be  made  demand 
operation;  those  the  result  of  debility  and  digestive  disturbance  require 
treatment  directed  to  these  conditions.  In  idiopathic  dilatation  hygienic 
remedies  should  be  employed,  such  as  massage  of  the  abdomen,  given 
gently  lest  ulceration  be  present;  electricity;  and  measures  for  the  improve- 

1  Centralbl.  f.  allgm.  Path.,  1907,  XXIX,  948. 
2. lour.  Amer.  Med.  Assoc,  1911,  LVII,  731. 


Fig.  256. — Idiopathic  Dilata- 
tion OF  THE  Colon. 
Child  of  2  years  and  1 
month,  in  the  Children's  Med- 
ical Ward  of  the  Hospital  of 
the  University  of  Pennsylvania. 
Obstinate  constipation  from 
birth,  sometimes  a  week  with- 
out stool,  distention  began  at 
5  months.  Maximum  girth  in 
hospital  283^  inches  (72.37). 
Right  inguinal  colotomy  per- 
formed. Temporary  relief  was 
followed  by  failure  of  strength 
and  death. 


INTESTINAL  OBSTRUCTION  781 

ment  of  the  general  health.  With  this  may  be  combined  the  administra- 
tion of  strychnine.  I  have  tried  pituitrine  without  benefit.  In  all  forms 
of  dilatation  the  unloading  of  the  bowels  by  purgatives  and  enemata  is  an 
unfortunate  necessity.  This  must,  however,  be  done  .as  infrequently  as 
possible,  as  it  tends  to  weaken  still  more  the  muscular  power  of  the  colon. 
High  injections  are  reciuired  for  this,  but  often  must  be  accompanied 
by  abdominal  massage  to  assist  in  expelling  the  liquid.  Puncture  of  the 
intestine  with  a  small  canula  and  the  drawing  off  of  the  gas  has  been 
practised  in  some  instances  when  the  distention  from  this  source  was 
great,  but  is  a  procedure  certainly  attended  by  danger.  In  all  severe 
cases  which  have  failed  to  be  benefited  by  other  treatment  the  question 
of  operative  interference  must  be  entertained.  It  should  be  done 
seasonably  before  weakness  has  become  too  great;  but,  on  the  other  hand, 
it  may  well  be  deferred  in  cases  in  young  subjects  in  which  dilatation  and 
constipation  are  the  only  symptoms  and  the  general  health  is  entirely 
unaffected.  The  possibihty  for  spontaneous  recovery  to  occur  should  be 
permitted,  inasmuch  as  the  operation  is  in  itself  attended  by  decided 
danger  to  life.  As  to  the  choice  of  operation  an  artificial  anus  can  be 
made  as  a  temporary  proceeding  or  resection  of  the  colon  performed. 
The  latter  is  the  only  satisfactory  procedure.  In  1  case  under  my 
observation,  apparently  ichopathic,  operation  consisted  in  an  incision 
partial^  through  a  constriction  dependent  upon  muscular  hypertrophy 
and  situated  in  the  upper  part  of  the  rectum.  Disappearance  of  the 
dilatation  followed;  but  this  case  should  manifestly  be  classified  under 
secondary  dilatation. 

INTESTINAL  OBSTRUCTION 

A  narrowing  or  a  complete  obliteration  of  the  lumen  of  the  intestine 
may  occur  in  any  portion  of  its  course.  It  may  be  congenital  or  acquired, 
and  may  be  due  to  many  causes.  Some  of  these  causes  are  symptomatic 
of  other  conditions  and  are  described  elsewhere.  In  other  cases  the 
obstruction  appears  to  be  primary,  or  at  least  the  most  important 
symptom. 

1.  Congenital  Stenosis  or  Atresia  of  the  Small  Intestine  and  Colon 

This  is  a  rare  condition.  Schukowsky'  ol)scrvcd  it  but  4  times  in 
20,000  new-born  children.  Although  possil)le  in  any  portion  of  the  tube, 
the  stenosis  is  found  oftenest  in  the  small  intestine,  and  much  less  fre- 
quently in  the  colon.  C'owelP  collected  from  medical  literature  92  cases 
of  occlusion  or  stenosis  of  the  duodenum,  these  including  the  57  previously 
carefully  analyzed  l)y  Cordes.''  Sometimes  only  one  portion  of  the 
intestine  is  involved;  sometimes  several.  The  lesion  varies  from  a  mere 
narrowing  to,  more  commonly,  complete  atresia,  and  this  may  vary  from 
involvement  of  a  very  small  portion  of  the  tube  up  to  sul)stituti()n  of  the 
entire  small  intestine  l)V  a  fibrous  cord.  In  some  cases  the  jiortions  ot  tiu; 
intestine  al)ov('  and  iu'low  the  affected  region  end  blindly,  the  intervening 
portion  having  entirely  disappeared.  The  intestine  al)()ve  theobi^truction 
is  much  distended,  that  below  is  collapsed.  Malformations  elsewhere 
in  the  body  may  occasionally  accompany  the  intestinal  deformity. 

'  Ref.,  Jahrl).  f.  Kiiidcrli.,  VMY-l  L\  III.  :V_>:i. 
2  (^uiirt.  .I(.ur.  of  M«'<1..  WH'-l,  V.  401. 
^  Arcli.  of  I'cd.,  1*M)1.  XVIII.  401. 


782  THE  DISEASES  OF  CHILDREN 

Etiology. — The  cause  of  congenital  stenosis  depends  upon  some 
pathological  process  or  developmental  defect  arising  during  fetal  life. 
The  nature  of  this  probably  varies  with  the  case.  Among  those  possible 
are  fetal  volvulus,  peritonitis  dependent  upon  syphilis  or  tuberculosis, 
intestinal  ulceration,  constriction  by  bands,  arrested  development,  fetal 
intussusception,  and  constriction  at  the  umbilical  ring.  In  some  in- 
stances the  stenosis  is  produced  by  the  pressure  by  a  tumor,  or  constriction 
by  a  Meckel's  diverticulum. 

Symptoms. — These  appear  soon  after  birth,  often  within  a  few 
hours.  In  atresia  or  great  stenosis  they  consist  of  obstinate  vomiting, 
colicky  pain,  complete  constipation  except  for  a  few  early  mucous  dis- 
charges, and  distention  of  the  abdomen,  the  seat  and  degree  of  this  last 
depending  to  some  extent  upon  the  situation  of  the  malformation.  It 
occupies  generally  the  umbilical  region,  leaving  the  flanks  flattened. 
When  the  obstruction  is  in  the  duodenum  or  high  in  the  jejunum  gaseous 
distention  is  absent,  or  slight  and  situated  in  the  epigastrium.  The 
higher  the  malformation  is  in  the  intestine,  the  sooner  does  vomiting  begin. 
The  vomited  matter  may  eventually  he  fecal  if  the  obstruction  is  low  in 
the  bowel.  The  general  condition  of  the  child  is  very  serious.  The 
face  is  pinched,  the  urine  scanty  or  suppressed,  there  may  be  dyspnea 
from  pressure  of  the  gas  against  the  diaphragm,  and  the  temperature  is 
low.  If  the  intestinal  stenosis  is  not  complete,  the  symptoms  are  of  the 
same  nature  but  less  severe. 

Course  and  Prognosis. — -The  prognosis  is  always-  most  grave. 
Death  results  from  collapse,  asthenia,  or  perhaps  convulsions.  In 
nearly  all  cases  it  occurs  in  less  than  a  week;  very  occasionally  not  before 
several  weeks  or  even  months,  if  the  intestinal  stenosis  has  been  less 
complete.  The  higher  the  malformation  is  in  the  intestine  the  shorter  is 
the  duration  of  life.  In  rare  instances,  where  the  stenosis  is  but  slight 
as  shown  by  autopsy,  the  patient  has  lived  for  some  years  and  even 
reached  adult  life. 

Diagnosis. — The  recognition  of  congenital  obstruction  of  the 
alimentary  tract  is  usually  not  difficult,  but  to  distinguish  that  of  the 
intestine  from  that  of  other  regions  may  sometimes  be  impossible.  In 
stenosis  of  the  esophagus  the  food  is  vomited  almost  at  once  after  swallow- 
ing, and  the  esophageal  sound  will  reveal  the  obstruction.  Pyloric 
stenosis  shows  the  gastric  peristaltis;  dilatation  of  the  stomach;  a  pyloric 
tumor  may  often  be  felt;  distention  is  confined  to  the  epigastrium  and 
the  vomitus  never  contains  bile.  The  course  of  the  disease  is  more 
prolonged  and  the  symptoms  less  severe  than  in  cases  of  intestinal  ob- 
struction. Stenosis  of  the  duodenum  cannot  be  distinguished  from  that 
of  the  pylorus  unless  the  obstruction  is  below  the  entrance  of  the  common 
bile-duct.  In  this  event  bilious  vomiting  will  occur.  The  vomiting 
takes  place  earlier  than  in  stenosis  lower  in  the  gut.  In  stenosis  of  the 
lower  ileum  or  colon  the  vomiting  is  later  in  appearance  and  is  eventu- 
ally fecal.  In  all  these  Rontgenological  studies  may  be  of  diagnostic 
value.  Idiopathic  dilatation  of  the  colon  cannot  be  differentiated  with 
certainty  from  some  of  the  rare  instances  in  which  a  moderate  congenital 
stenosis  of  the  colon  has  been  present,  as  in  a  case  reported  by  Treves.^ 
Stenosis  of  the  rectum  may  be  detected  by  local  examination.  The  early 
and  rapid  development  of  the  symptoms  distinguishes  congenital  stenosis 
from  that  dependent  upon  fecal  impaction,  intussusception,  volvulus,  and 
the  hke. 

'  Lancet,  1898,  I,  276. 


INTESTINAL  OBSTRUCTION  783 

The  treatment  can  be  only  surgical.  Operation  should  be  done  as 
promptly  as  possible,  yet  the  results  of  this  at  the  early  age  have  been 
entirely  unpromising. 

2.  Congenital  Stenosis  or  Atresia  of  the  Rectum  or  Anus 

This  is  very  much  the  most  frequent  variety  of  intestinal  obstruction, 
although  still  uncommon.  Several  forms  of  this  condition  occur,  and 
atresia  is  more  common  than  stenosis.  There  may  be  complete  closure 
of  the  anus  with  entirelj'  normal  intestine  above  this.  This  is  the  variety 
most  frequently  encountered.  In  a  second  form  not  only  is  the  anus 
closed  but  the  rectum  above  it  exhibits  atresia  for  an  extent  varying  with 
the  case.  In  still  a  third  variety  the  anus  and  the  part  of  the  rectum 
immediately  above  it  are  normal  but  are  separated  by  a  membrane  from 
the  patulous  rectum  farther  up.  In  the  third  form  the  presence  of  an 
accumulation  of  fecal  matter  beyond  the  separating  membrane  can 
sometimes  be  detected  by  the  palpating  finger  introduced  into  the  anus. 
In  the  other  varieties  this,  of  course,  cannot  be  done.  Anj^  one  of  the 
forms  may  be  combined  with  anomalous  communication  with  the  vagina, 
bladder,  or  urethra,  or  exhibit  a  fistula  into  the  peritoneum  or  elsewhere. 
Leichtenstern^  found  such  communication  in  40  per  cent,  of  the  cases. 
Malformations  in  other  regions  of  the  body  may  likewise  be  present. 

The  symptoms  are  those  of  intestinal  obstruction  situated  else- 
where, but  coming  on  later  than  in  this  latter  condition.  Inspection  or 
digital  exploration  of  the  anal  and  rectal  region  will  disclose  the  malforma- 
tion. Operation  should  be  done  as  early  as  possible.  This  is  easy  where 
there  is  merely  an  occlusion  of  the  anus  or  an  obstruction  of  the  rectum  by 
thin  membrane.  Where,  however,  the  rectum  is  obliterated  to  any  a 
extent  it  is  a  more  serious  matter.  An  artificial  anus  must  be  made  in 
some  such  cases  for  temporary  relief,  leaving  for  a  later  period  the  more 
difficult  plastic  operation  which  will  connect  the  rectal  cul-de-sac  with 
the  anal  region.  The  plastic  closing  of  any  abnormal  opening  which  has 
been  made  can  be  done  at  the  same  time.  The  statistics  of  the  mortality 
with  the  various  operations  which  have  been  employed  in  90  collected 
cases  have  been  carefully  analyzed  by  Ashhurst.^ 

3.  Acquired  Intestinal  Obstruction 

This  may  be  due  to  various  causes,  some  of  which  must  receive  sepa- 
rate consideration.  A  Meckel's  diverticulum,  (p.  SOD)  or  a  fibrous  cord 
constituting  its  remainder  or  produced  in  other  ways,  as  by  a  fetal 
peritonitis,  may  sometimes  compress  the  intestine  or  even  strangle  it. 
This  may  occur  at  any  time  in  childhood  or  in  adult  life.  In  some  cases 
the  intestine  is  caught  in  retroperitoneal  recesses,  or  in  abnormal  openings 
in  the  mesenter}'.  \'olvulus  is  another  factor  uncommon  in  early  life. 
Peritonitis  may  cause  obstruction,  either  l)y  the  production  of  fil)rous 
bands,  as  occasionally  .seen  in  tul)erculous  peritonitis,  or  l)y  i)aralysis 
of  peristalsis  and  the  consequent  fecal  accumulation.  Appendicitis 
acts  in  a  similar  manner.  Foreign  bodies  in  the  intestine,  including 
here  especially  a  fecal  impaction,  are  occasionally  causes,  as  are  tumors 
pressing  upon  the  intestine,  and  rarely  a  mass  of  ascarides  in  the  bowel. 
Of  this  last   Doberaner"*   collected   24   rei)orted  instances.     IVrret    and 

'  Zieinsson  Haiidh.  spec.  Patli.  u.  'I'lK'nij).,  1S7.'),  VII,  2,  3G1). 
=  Univ.  of  Pcnna.  Med.  Hull.,  1907.  XX.  <H>. 
'  PraR.  lucd.  VVochonschr.,  1914,  XXXIX,  197. 


784 


THE  DISEASES  OF  CHILDREN 


Simon ^  have  added  others,  includino;  an  interesting  case  observed  and 
figured  by  them  (Fig.  257).  An  incarcerated  strangulated  hernia  is  an 
occasional  cause  in  children.  By  far  the  most  frequent  cause,  however, 
is  intussusception. 

The  symptoms  of  most  of  these  conditions  develop  suddenly  and  are 
very  similar  to  those  in  congenital  cases,  as  already  described;  but  the 
diagnosis  of  the  cause  of  the  obstruction  is  often  impossible.  Intus- 
susception and  hernia  will  receive  separate  consideration. 


Fig.  257. — Intestinal  Obstruction  by  Ascarides. 
A  mass  of  approximately  40  worms  expelled  in  a  case  of  acute  intestinal  obstruction  in  a 
girl  of  8  years.     (Perret  and  Simon,  Jour.  Amer.  Med.  Assoc,  1917,  LXVIII,  245.) 

The  prognosis  is  more  favorable-  than  in  congenital  stenosis,  since 
the  patient  is  older  and  the  tolerance  for  operative  interference  conse- 
quently greater,  and  since  the  cause  is  frequently  a  removable  one. 

■  INTUSSUSCEPTION 

Etiology. — The  disease  constitutes  one  of  the  more  frequent  forms  of 
intestinal  obstruction  in  children.  Decidedly  over  half  of  the  cases 
occur  in  the  1st  year  of  life  and  most  of  the  remainder  in  the  2d  year. 
It  is  unusual  in  the  first  3  months,  but  has  })een  seen  as  early  as  the  2d 
day.  In  293  cases  collected  by  Pilz-  158  were  in  the  1st  year.  In  314 
cases  studied  by  Hess^  201  were  in  the  1st  year,  but  only  8  cases  in 
the  first  3  months;  the  2  youngest  in  children  each  6  days  old.  Of  397 
Danish  cases  reported  by  Koch  and  Oerum^  60  per  cent,  were  in 
the  1st  year  and  66  per  cent,   of  these  in   children  of   from  4   to  8 

'  Journ.  Amer.  Med.  Assoc,  1917,  LXVIII,  244. 

2  Jahrb.  f.  Kinderh.,  1870,  III,  1. 

3  Arch,  of  Ped.,  190.5,  XXII,  6.5.5. 

^  Mitteilungen  aus  d.  Grenzgeb.  der  Med.  und  Chir.,  1913,  XXV,  29.3. 


INTUSSUSCEPTION 


/So 


Return^ 


f^ecet.L/iny 


months.  Of  their  161  cases  occurring  after  the  age  of  1  year,  all 
but  30  were  not  over  6  years  of  age.  The  disease  is  from  2  to  3  times  more 
common  in  males  than  in  females.  The  occurrence  of  diarrheal  con- 
ditions occasionally  predisposes,  as  does  constipation  and  cohc;  but  in 
most  instances  intussusception  develops  in  those  who  have  been  in  appar- 
ently perfect  health.  Abnormal  conditions  of  Meckel's  diverticulum 
have  been  reported  as  the  cause  in  a  number 
of  instances.  I  have  reviewed  this  subject 
elsewhere.^  The  vermiform  appendix  may 
in  rare  instances  invaginate  itself  and  be 
the  cause  of  intussusception  of  the  intestine 
(Monsarrat).^  Corner^  was  able  to  collect 
16  reported  cases  of  this  occurrence.  Injuries 
of  the  abdomen  are  also  to  be  noted  as  occa- 
sional causes.  The  presence  of  large  fecal 
masses  or  of  polypi  tends  to  produce  invagina- 
tion through  the  efforts  of  the  intestines  to 
expel  them.  Finally  agonal  intussusception  is 
of  quite  frequent  occurrence  in  infancy,  caused 
by  irregular  peristalsis  of  the  intestine  de- 
veloping in  the  few  moments  preceding  death. 

Pathology  and  Pathological  Anatomy. — The  condition  consists 
in  an  invagination  of  one  portion  of  the  intestine  into  another,  the  result 
of  irregular  contraction  and  peristalsis  of  the  intestinal  walls.  The  in- 
vagination is  descending  in  type,  an  ascending  invagination  being  very 
rare.     The  upper  portion,  the  intussusceptum,  slips  into  the  lower,  the 


Fig.  258. — Diagrammatic 
Represent.\.tion  of  the  Pro- 
DicTiox  OF  Intussusception. 
{Kemp,  Diseases  of  the  Stomach, 

Intestines  and  Pancreas.) 


Fig.  259. — Intussusception. 
Intussuscipiens  to  the  left.     Courtesy  of  Dr.  Robert  LeConte. 

intussuscipiens,  pulling  the  mesentery  with  it.  The  intussusception  thus 
consists  of  three  thicknesses  of  intestinal  wall,  two  mucous  surfaces  being  in 
apposition,  and  two  serous  likewise  (Fig.  258).  The  (h'agging  upon  the 
mesentery  makes  tlui  intestine  assume  a  curved,  sausage-shaped  form, 
with  the  concavity  toward  the  mesenteric  attachment  to  the  spinal  column 
(Fig.  259).     Although  tiie  bowel  can  remain  patulous  and  the  circulation 

'  .loiir.  Amor.  Mod.  .Assoo.,  1!)1 4.  LXII.  1()24. 
=  Liv«-r|).)i)l  Mod.-Cliir.  .Jour..  I'.XH,  X.\I,  68. 
3  Aniuils  of  Surg.,  1903,  XXXVlll,  OUU. 
50 


786 


THE  DISEASES  OF  CHILDREN 


of  blood  in  it  be  preserved,  this  is  usually  not  the  case,  but  swelling  prompt- 
ly begins  as  a  result  of  compression  of  the  blood-vessels.  This  not  only 
produces  complete  intestinal  obstruction  but  an  incarceration  of  the  intus- 
susception, which  later  becomes  irreducible  through  the  adhesive  inflamma- 
tion between  the  adjacent  serous  surfaces.  The  mucous  membrane  is  deep- 
red,  especially  the  apex  of  the  intussusceptum,  and  finally  strangulation 
takes  place  with  more  or  less  complete  death  of  the  part.  In  the  for- 
tunate, but  I'are,  cases  this  may  become  entirely  separated  by  the  gan- 
grenous process,  and  discharged  through  the  anus,  while  the  adhesions 
formed  between  the  bowel  and  the  neighboring  tissues  and  between  the 
contiguous  coats  of  the  bowel  itself  serve  to  reestablish  the  lumen  of  the  gut. 

The  intussusception  does  not,  however,  become  irreducible  through 
adhesive  inflammation  for  several  days  and  sometimes  even  a  week. 
Previous  to  this  it  is  the  swelhng  which  prevents  the  intestine  resuming 
its  normal  position.  The  time  when  gangrene  begins  varies  greatly, 
it  developing  more  frequently  and  sooner  in  the  acute  cases.  The  in- 
testine above  the  intussusception  is  generally  dilated,  that  below  it 
contracted. 

Intussusceptions  are  classified  according  to  their  situation: 

1.  Ileac  (enteric)  intussusception  affects  the  small  intestine  in  any 
part,  and  usually  this  only.  It  is  less  often  seen  than  some  other  forms 
in  early  life,  but  one  of  the  more  common  after  the  period  of  childhood. 
This  does  not  apply  to  the  agonal  variety  which  is  not  uncommon  in 
infancy,  involving  as  many  as  from  6  to  12  different  positions  in  the  small 
intestine,  being  most  frequent  in  the  jejunum.  Agonal  intussuscep- 
tion shows  no  evidence  of  inflammation  or  swelling,  and  is  without 
clinical  significance. 

2.  Colic  intussusception  may  afi"ect  any  part  of  the  colon.  It  is  one 
of  the  more  common  varieties,  yet  not  as  often  seen  as  the  ileocecal. 

3.  Ileocolic  intussusception  exhibits  invagination  of  the  ileum 
through  the  ileocecal  valve.  The  cecum  may  then  be  invaginated 
secondarily,  but  the  ileum  remains  as  the  most  prominent  protruding 
portion.     This  is  the  least  frequent  variety  of  intussusception. 

4.  Ileocecal  intussusception  is  the  form  oftenest  seen,  and  the 
younger  the  child  the  more  likely  is  the  invagination  to  be  of  this  sort. 
In  this  the  cecum  with  the  ileum  behind  it  passes  into  the  colon,  the 
valve  continuing  to  bo  the  apex  of  the  projecting  portion. 

Besides  these  types  mixed  forms  of  various  sorts  may  occasionally 
occur,  including  instances  of  double  intussusception.  The  relative 
frequency  of  the  four  main  types,  as  occurring  in  children,  seems  to  vary 
somewhat  according  to  the  statistics  given,  yet  the  differences  are  not 
great.  This  may  be  seen,  for  instance,  in  the  180  cases  of  Leichtenstern^ 
under  10  years  of  age  and  the  380  cases  of  Koch  and  Oerum.^ 


Table 

81. — Frequency  of  Intussu.sception, 

Leichtenstern 

180  Cases 

Variety 

Under  2  years, 
per 'cent.. 

2-5  years, 
per  cent. 

6-10  years, 
per  cent. 

Ileocecal  

Ileac 

Colic. 

Ileocolic 

70 
6 

19 
4 

49 
13 
25 
13 

41 

38 
21 
0 

1  Prag.  Vierteljahrsch.  f.  prakt.  HeUk.,  1873,  CXVIII-CXIX,  188,  et  seq. 
^Loc.  cit.;  301. 


Variety 

unaer  i  year, 
per  cent. 

Ileocecal *. 

49.5 
2.6 

12.0 
3.5 
3.9 

28.0 

Ileac 

Colic 

Ileocolic 

Mixed ....                            

Undetermined . . 

INTUSSUSCEPTION  787 

Table  82. — Frequency  of  Intussusceptiox.  Koch  and  Oerum.     380  Cases 

i 

Over  1  year, 
per  cent. 

38.0 
9.2 

23.7 
1.3 
1.9 

25.7 

Koch  and  Oerum  maintain  that  the  larger  proportion  of  the  cases  called 
"undetermined"  could  with  propriety  be  placed  among  the  ileocecal. 

As  time  passes  the  intussusception  of  all  varieties  is  prone  to  in- 
crease in  size,  the  apex  always  remaining  unchanged  and  the  intussus- 
cipiens  invaginating  more  and  more.  As  a  result  the  ileocecal  form 
may  finally  occupy  all  of  the  rectum,  and  the  apex  of  the  intussusception 
nearly  reach  the  anus  or  even  pass  through  it. 

Double  intussusceptions  are  less  frequent,  probably  over  90  per  cent, 
being  single  (Corner).^  For  instance,  an  enteric  intussusception  may  ex- 
tend downward  to  the  cecum,  and  then  push  the  cecum  before  it, 
producing  a  secondary  ileocecal  invagination.  Double  intussusception 
of  other  forms  may  occur. 

Symptoms.^ — With  or  without  previous  evidence  of  intestinal 
disturbance  the  child  is  suddenly  attacked  by  severe  pain,  vomiting, 
restlessness  and  great  prostration.  The  face  is  pinched,  the  eyes  sunken, 
the  pulse  feeble  and  rapid,  the  urine  scanty,  the  temperature  normal  or 
below  it.  The  abdomen  is  at  first  soft;  later  distended  and  often  tender. 
The  fecal  matter  present  in  the  colon  and  rectum  is  evacuated  during 
the  1st  day,  but  after  this  fecal  movements  are  very  small  in  amount 
or  more  often  entirely  absent,  and  Httle  if  any  gas  is  passed  by  the  bowel. 
Pain  comes  on  in  paroxysms,  attended  by  straining  efforts  if  the  intus- 
susception has  reached  the  rectum,  and  by  the  frequent  passage  of  small 
(|uantities  of  l)Jood-stained  mucous,  or  even  of  blood  in  considerable 
(luantity.  Blood  generally  appears  in  the  first  12  hours,  but  sometimes 
not  for  1  or  2  days.  This  condition  of  the  bowel  movements  is  one  of 
the  most  characteristic,  but  may  be  wanting  in  some  cases.  Absolute 
failure  of  evacuation  of  fecal  matter  and  of  gas  is  most  common  in 
enteric  invagination,  and  in  these  cases,  too,  hemorrhage  from  the 
bowel  may  be  later  in  appearing,  or  absent  entirely.  Although  vomiting 
continues  ver}^  persistent  and  frequent  it  is  always  a  less-niarkod  symp- 
tom than  in  other  forms  of  intestinal  obstruction.  It  is  usually  worst  at 
the  b(!ginning,  l)ut  may  continue  severe  throughout  the  attack;  or  it 
may  sometimes  occur  only  a  few  times  daily.  It  is  most  marked  in 
enteric  intussusception.  Stercoraceous  vomiting  is  seen  in  only  a  small 
proportion  of  cases  antl  generally  not  until  late.  Pain,  too,  is  a  varial)le 
symptom.  Sometimes  intensely  severe  and  causing  loud  outcries,  it 
may  be  evidenced  only  by  the  grunting  sounds  which  attend  the  accom- 
panying tenesmus.  It  is  usually  most  intense  early  in  the  attack.  In 
children  old  enough  to  describe  it,  it  may  l)e  localized  in  the  region  of 
the  intussusception  or  about  the  innbilicus.  A  tumor  is  discoverabk'  in 
the  majority  of  instances.  It  can  often  be  found  very  early  in  the  disease, 
even  on  the  1st  day,  and  may  reach  the  anus  by  the  2d  tlay,  although 

'  Loc.  ciu,  690. 


788  THE  DISEASES  OF  CHILDREN 

usually  later  than  this.  It  can  very  frequently  be  felt  in  the  rectum  and 
then  gives  to  the  finger  a  sensation  very  like  that  of  the  vaginal  portion 
of  the  uterus,  the  lumen  of  the  bowel  corresponding  to  the  os.  Koch  and 
Oerum^  maintain  that  a  tumor  was  found  by  abdominal  palpation  or  by 
rectal  examination  in  85.5  per  cent,  of  their  380  cases.  As  to  the  position 
occupied,  as  shown  by  abdominal  palpation,  it  was  upon  the  left  side, 
either  the  upper  or  lower  quadrant,  in  over  50  per  cent,  of  the  cases. 
In  about  33  per  cent,  the  tumor  had  been  discovered  by  rectal  examina- 
tion. During  the  paroxysm  of  pain  rectal  palpation  shows  the  tumor 
temporarily  increasing  in  size  and  approaching  nearer  to  the  anus.  When 
protruding  from  the  anus  it  may  have  the  appearance  of  a  rectal  pro- 
lapse or  a  polypus  or  hemorrhoid.  Felt  through  the  abdominal  walls 
between  the  paroxysms  of  pain  the  tumor  may  occupy  various  positions 
depending  upon  the  seat  of  the  intussusception.  In  the  commoner  ileo- 
cecal form  it  is  situated  usually  in  the  region  of  the  descending  colon 
curving  around  the  umbilicus  from  above  to  the  left  side.  In  the  ileo- 
colic form  the  tumor  is  upon  the  left  side  extending  from  the  costal 
border  downward,  but  without  arching  about  the  navel.  In  enteric 
intussusception  a  tumor  can  seldom  be  detected. 

The  symptoms  described  are  those  characteristic  of  most  acute  cases. 
At  times,  however,  instances  occur  in  which  many  of  the  symptoms  are 
so  little  marked  that  the  disease  may  be  entirely  overlooked  if  sufficient 
attention  is  not  paid  to  the  condition  of  the  bowel-movements  and  the 
discovery  of  a  tumor.  Occasionally  cases  are  more  subacute  in  nature, 
the  onset  being  more  gradual,  the  pain  and  vomiting  less  severe  and  con- 
stipation less  complete.  Still  other  exceptional  cases,  seen  only  in  older 
children,  are  of  a  more  chronic  nature,  in  which  the  occlusion  is  not  com- 
plete and  the  circulation  in  the  mesenterj^  not  entirely  shut  off.  There 
is  little  pain  or  vomiting,  no  definite  intestinal  symptoms,  and  no  bloody, 
mucous  movements.  Diarrhea  may  replace  constipation.  The  symp- 
toms may  come  in  attacks  separated  by  intervals  of  comparative  health, 
and  suggest  recurrences  of  catarrh  of  the  large  intestine.  The  patients 
gradually  lose  strength  or  may  suffer  suddenly  from  symptoms  of  stran- 
gulation, as  in  an  acute  attack.  Only  the  discovery  of  a  tumor  makes  a 
diagnosis  possible. 

Course  and  Prognosis. — If  the  reduction  is  accomplished  the  tumor 
can  no  longer  be  felt,  and  all  the  other  symptoms  rapidly  disappear.  If 
this  has  not  taken  place  the  course  of  the  disease  is  progressively  onward 
to  a  fatal  issue.  A  few  exceptions  are  seen  in  which  spontaneous  reduc- 
tion occurs,  or  in  which  gangrene  and  subsequent  discharge  of  the  invag- 
inated  bowel  take  place  and  the  patient  survives  the  septic  condition 
and  risk  of  perforation.  Cicatricial  stenosis  may  develop  later  in  such 
instances. 

Death  is  the  result  generally  of  collapse  from  the  shock  which  the 
intestinal  lesion  produces.  In  the  more  subacute  or  chronic  cases  it 
follows  from  increasing  exhaustion,  sometimes  with  a  final  rise  of  tem- 
perature to  a  considerable  height.  Death  from  peritonitis  is  not  common. 
The  average  duration  of  acute  fatal  cases  without  operation  is  a  week 
or  sometimes  less,  with  a  range  of  1  day  up  to  2  or  3  weeks.  Chronic 
cases  may  last  for  months. 

There  is  often  seen  a  disposition  for  the  intussusception  to  relapse 
after  successful  reduction.  This  takes  place  with  greatest  frequency 
on  the  first  day  after  reduction  has  been  accomplished,  but  may    be 

'  Loc.  cit.,  338. 


INTUSSUSCEPTION  789 

much  delayed.  It  sometimes  happens  that  this  occurrence  takes  place 
several  times.  Some  of  these  cases  are  certainly  mistaken  instances  of 
relapse;  it  being  supposed  that  reduction  has  occurred,  when,  in  reality, 
this  did  not  happen.  Undoubtedly  relapse  is  possible,  although  not 
very  frequent.  Koch  and  Oerum^  found  10  such  cases  in  their  list, 
with  9  other  doubtful  ones  and  6  instances  of  recurrence  at  later  periods. 

The  -prognosis  is  alwaj's  grave  especially  in  acute  cases,  although  less 
so  than  formerly.  The  younger  the  patient  the  more  serious  the  con- 
dition. Untreated  cases  are  practically^  always  fatal.  The  probability 
of  recovery  varies,  too,  directl}^  in  proportion  to  the  quickness  with  which 
the  diagnosis  is  made  and  treatment  instituted.  In  general  the  average 
mortality  at  the  present  da}^  including  cases  not  operated  upon,  may  be 
placed  at  60  to  70  per  cent.  In  the  314  cases  reported  by  Hess-  211  re- 
covered and  103  died.  Leichtenstern's^  figures  gave  a  total  mortality 
of  73  per  cent,  for  557  cases  of  all  ages.  In  the  1st  year  the  mortality 
was  86  per  cent.  The  death-rate  has  lessened  since  operative  inter- 
ference has  become  more  common  and  the  technique  better.  Thus 
Weiss*  in  322  collected  cases  of  all  ages  found  the  mortality  in  infancy 
(177  cases)  without  operation,  84  percent.;  with  primary  laparotomy, 
39  per  cent.;  with  secondary  laparotoni}^  after  unsuccessful  treatment 
of  other  sorts,  46  per  cent.  In  childhood  (85  cases)  without  operation, 
78  per  cent.;  in  primarj^  laparotomy,  10  per  cent.;  in  secondary-  lapar- 
otomy after  other  unsuccessful  treatment,  50  per  cent.  The  chance  of 
recovery  depends,  too,  upon  the  promptness  with  which  operation  is 
performed.  Gibson^  in  187  operative  cases,  collected  since  antiseptic 
methods  have  improved,  shows  this  well,  the  mortality  in  patients 
operated  upon  on  the  1st  day  being  37  per  cent.;  on  the  2d  day,  39 
per  cent.;  3d  day,  61  per  cent.;  4th  day,  67  per  cent.;  5th  day,  73  per 
cent. ;  and  6th  day,  75  per  cent. 

Diagnosis. — This  usually  presents  little  difficulty.  The  cardinal 
diagnostic  symptoms  are  the  sudden  development  of  abdominal  pain, 
vomiting,  tenesmus  and  bloody  stools  without  fecal  matter,  prostration 
and  absence  of  fever.  The  diagnosis  is  made  certain  by  the  discovery 
of  a  tumor.  Perplexities,  however,  arise  at  times  and  mistakes  are  far 
from  uncommon.  The  bloody,  mucous  movements  may  be  mistaken  for 
colitis.  Conversely  colitis  may  be  supposed  to  be  intussusception,  and 
I  have  seen  operation  urged  accordingly.  The  earlier  occurrence  of 
diarrhea  and  the  presence  of  fecal  matter  and  especialh'  fever,  aid  in 
the  recognition  of  the  inflammatory  disorder.  Henoch's  purpura,  with 
hemorrhage  into  the  lumen  and  the  walls  of  the  intestine,  may  strongly 
suggest  intussusception,  but  the  presence  of  evidences  of  purjiura  else- 
where aid  in  distinguishing  it.  It  is  possible,  however,  for  purpura  to  be 
attended  by  intussusception,  and  a  number  of  such  cases  have  been 
reported.  The  protruding  of  an  intussuscejition  fiom  the  rectum  accom- 
panied by  straining  and  the  passing  of  mucus  may  sometimes  strongly 
suggest  prolapse  of  the  rectum.  I  have  known  the  two  conditions  to  be 
combined.  As  stated,  the  discovery  of  a  tumor  usually  removes  doubt, 
but  as  this  is  often  difficult,  especially  through  the  ab(lonii?ial  wall,  in  all 
questionable  casesa  careful  examination  should  be  made  umler  anesthesia, 

» Loc.  cit.,  326. 
^  Loc.  cit. 
'  Loc.  cit. 

*  Ccntrall)!.  f.  d.  (Irciizucl).  d.  Mc.l.  uii.l  ( "hirurg.,  18'jy,  11,  702. 

*  Arch,  of  Ped.,  19()0.  XVII,  09. 


790  THE  DISEASES  OF  CHILDREN 

Enteric  intussusception  seldom  has  a  discoverable  tumor  and  there  is  no 
tenesmus,  and  these  cases  cannot  with  certainty  be  distinguished  from 
instances  of  acute  intestinal  obstruction  from  other  causes.  It  is  to  be 
remembered  also  that  appendicitis  is  attended  by  the  development  of  a 
tumor  and  often  by  constipation.  There  are,  however,  no  bloody  stools 
and  tenesmus,  and  the  tumor  occupies  usually  the  region  of  the  cecum, 
is  more  superficial,  and  of  a  different  shape.  In  typical  cases  of  intussus- 
ception, the  injection  of  bismuth  and  the  taking  of  an  x-ray  picture  may 
be  of  diagnostic  aid,  as  in  a  case  reported  by  Snow  and  Clinton.^ 

Treatment. — ^As  soon  as  the  diagnosis  is  made  in  cases  which  have 
lasted  only  1  or  2  days  determined  efforts  may  be  made  to  reduce  the 
intussusception  by  other  than  surgical  measures.  The  child  should  be 
anesthetized,  the  hips  elevated,  and  the  patient  now  and  then  held 
inverted.  Injections  should  meanwhile  be  given  of  either  air,  water, 
or  oil.  There  is  probably  no  great  danger  of  rupture  of  the  intestine 
with  proper  precautions,  but  the  pressure  with  air  can  be  less  accurately 
controlled  than  that  with  liquid.  Air  may  be  injected  from  a  bulb- 
syringe  or  hand-bellows  attached  to  a  catheter.  The  anus  must  be  com- 
pressed around  the  tube  by  the  fingers,  and  the  injection  given  slowly 
and  carefully.  In  place  of  this,  oil,  or  a  warm  normal  saline  solution, 
may  be  employed.  The  liquid  should  be  in  a  fountain  syringe  which  may 
be  elevated  not  over  6  feet  (173  cm.)  above  the  bed  on  which  the  child 
lies;  the  pressure  being  maintained  for  15  or  20  minutes.  If  successful,' a 
rumbling  sound  can  sometimes  be  heard ;  the  tumor  entirely  disappears, 
ver}'  careful  examination  being  necessary  to  make  sure  of  this;  the  dis- 
tention produced  by  the  gas  or  liquid  employed  ceases  to  exist;  the 
aspect  of  the  child  improves;  vomiting  stops;  and  a  fecal  stool  may 
shortly  occur.  If  unsuccessful,  or  if  the  result  is  uncertain,  the  liquid  or 
air  must  be  allowed  to  escape  and  the  procedure  tried  once  again.  If 
still  there  is  no  success,  operative  aid  must  be  had  immediately,  and  the 
intussusception  found  and  reduction  accomplished  b}^  withdrawing  the 
invaginated  portion  if  this  is  possible.  In  fact,  owing  to  the  frequent 
impossibility  of  determining  accurately  whether  reduction  has  been 
accomplished,  or  of  knowing  what  may  be  the  condition  of  the  intestinal 
wall,  it  is  safer  to  regard  all  cases  as  purely  surgical,  and  to  proceed  at 
once  with  operation  for  reduction,  without  attempting  any  medical 
treatment.  In  cases  coming  late  to  operation  adhesion  and  swelling 
may  prevent  reduction;  or  the  condition  of  the  bowel  may  be  such  that 
enterostomy  is  necessary,  and  either  an  artificial  anus  must  be  made,  or  a 
resection  of  the  intestine  performed. 

On  account  of  the  danger  of  recurrence  of  the  trouble  after  either 
mechanical  or  operative  reduction,  peristalsis  should  be  quieted  as  far 
as  possible  by  small,  repeated  doses  of  an  opiate.  A  purgative  should 
never  be  administered. 

HERNIA 

Hernia  in  children  is  of  several  varieties.  Those  deserving  special 
mention  are:  (1)  Umbihcal;  (2)  Inguinal;  (3)  Diaphragmatic,  and  (4) 
Ventral.  Of  these  the  umbilical  and  inguinal  are  far  the  most  frequent. 
Femoral  hernia  is  so  uncommon  that  further  reference  need  not  be  made 
to  it.  The  rare  internal  hernias  other  than  the  diaphragmatic  will 
also  be  omitted. 

lAmer.  Jour.  Dis.  Child.,  1913,  VI,  93. 


HERNIA  791 

1.  Umbilical  Hernia 

Hernia  of  the  intestine  at  the  umbiHcus  may  be  either  (a)  congenital 
or  (6)  acquired. 

(a)  Congenital  Umbilical  Hernia  (Hernia  into  the  Cord).— This 
is  a  very  uncommon  condition ;  of  which  I  can  recall  seeing  not  more  than 
2  instances.  Lindfors'  in  20,735  births  found  it  present  in  the  ratio  of 
1 :  5184.  The  hernia  forms  a  tumor,  oval,  round  or  conical  in  shape,  and 
of  the  size  of  a  walnut  up  to  that  of  an  orange  or  larger.  The  sac 
appears  to  be  composed  of  the  distended  umbihcal  cord,  its  walls  con- 
sisting only  of  peritoneum  and  of  the  amnion  of  the  cord,  and  being  of  a 
greenish-white  color  and  transparent  character.  The  contents  are 
usually  coils  of  intestine,  but  sometimes  the  stomach,  the  spleen,  or  all 
or  part  of  the  liver,  may  be  found  in  it.  The  color  of  these  is  readily 
distinguishable  through  the  sac-walls.  The  size  and  tension  of  the  mass 
increase  with  crying  or  coughing.  The  hernia  can  sometimes  be  reduced, 
sometimes  not;  and  when  of  small  size  recovery  may  take  place  spon- 
taneously with  the  process  of  the  separation  of  the  cord.  In  this  event  a 
reactive  inflammation  sets  in  around  the  ring-shaped  border  of  the  hernia, 
the  color  of  the  sac  changes,  and  the  umbilical  cord  shrinks  and  finally 
it  and  the  amnion  separate.  Granulations  then  spread  gradually 
over  the  surface  remaining,  generally  with  free  suppuration.  As  the 
wound  thus  left  heals  and  shrinks  the  hernia  disappears  within  the 
abdominal  cavity.     A  cicatrix  remains  but  no  real  navel. 

Many  dangers,  however,  attend  this  process  and  a  fatal  issue  generally 
results.  Peritonitis  is  very  liable  to  occur,  the  hernia  becomes  gangrenous 
or  general  sepsis  develops.  The  prognosis  is  on  the  whole  grave.  By  far 
the  larger  proportion  of  patients  died  until  the  radical  operation  was  in- 
troduced and  perfected,  and  even  still  the  mortality  is  high.  In  the 
case  of  very  large  hernia,  with  the  presence  in  the  sac  of  a  considerable 
portion  of  the  abdominal  contents,  the  continuance  of  the  child's  life  is 
scarcely  possible.  In  91  instances  of  hernia  of  the  cord,  collected  by  Loth- 
eisen^  the  mortaUty  in  the  68  operated  cases  equalled  29.4  per  cent.,  and 
in  the  23  unoperatcd  cases  65.22  per  cent.  Somewhat  similar  statistics 
are  given  by  Safford''  with  a  mortaUty  of  33  per  cent,  in  73  operated  cases, 
and  53  per  cent,  in  15  uiiopeiated  cases.  Sometimes  the  sac  breaks 
during  birth,  leaving  the  child  partly  eviscerated.  Very  often  other 
malformations  are  present.  Not  infrequently  the  infants  are  premature 
or  still-born. 

The  diagnosis  is  readily  made  except  in. the  case  of  small  cylindrical 
hernias  into  the  cord.  Here  it  is  easy  to  overlook  the  condition  and  to 
apply  a  ligature,  which,  of  course,  ligal(>s  the  intestine  as  well.  Every 
child  born  with  the  cord  decidedly  swollen  close  to  the  body  should  be 
examined  very  car(^fully  before  a  ligatui'c  is  applied. 

Treatment  consists,  first  of  all,  in  the  greatest  care  in  handling  a 
congenital  hernia  and  in  the  use  of  every  possible  antiseptic  precaution. 
If  the  rupture  is  small  and  if  reduction  can  be  made  quite  easily,  this  may 
be  done  and  an  antiseptic  compr(>ss  applied  and  attached  with  adhesive 
plaster.  The  child  must  not  be  lifted  into  an  upi'ight  position  until  the 
wound  has  completely  cicatrized,  and  this  may  re(iuire  weeks.  If  the 
hernia  is  not  reducible,  it  may  be  covered  with  an  antiseptic  protective 
dressing  in  the  hope  that  granulations  may  form  and  the  process  go  on 

'  VolkmaiHi's  SammliiiiK  kliii.  \'()rtr!iKO,  1S!);J.  ii.  s.  {\.\.  Gviiiic.  No.  '2(),  (324. 
2  Wiener  kliii.  Kuiulsclmu,  liM)3,  XVII,  7.')?. 
»  Phila.  Med.  Jour.,  1901,  VII,  iWi. 


'92 


THE  DISEASES  OF  CHILDREN 


as  just  described.  A  much  more  successful  plan  of  treatment,  however, 
applicable  also  to  the  small,  reducible  hernias,  is  the  performing  of  a 
radical  operation  as  soon  after  birth  as  possible  and  without  any  previous 
efforts  at  reduction  being  made.  The  operation  may  be  done  either  with 
or  without  the  opening  of  the  peritoneum.  The  temperature  of  the  child 
should  later  be  maintained  by  the  use  of  external  heat  as  in  the  treat- 
ment of  premature  infants. 

(6)  Acquired  Umbilical  Hernia. — This  is  a  very  common  and 
seldom  serious  affection  of  infancy.  It  generally  develops  in  the  first 
few  months  of  life,  and  is  seen  most  frequently  in  thin  children  or  in  those 
with  indigestion  and  flatulent  distention  of  the  abdomen  from  other 


Fig.  260. — A  Mild  Degree  of  Acquired  Umbilical  Hernia. 
(Hecker  and  Trumpp,  Atlas  of  Diseases  of  Children,  A?nerican  Translation,  Fig.  22,  p.  82.) 

causes.  Infants  in  whom  there  is  much  crying  or  such  pressure  as  may 
attend  constipation  are  also  predisposed  to  it.  The  influence  of  phi- 
mosis through  straining  efforts  is  considered  very  questionable.  The 
hernia  appears  oftenest  as  a  small  elastic  tumor  covered  with  skin,  not 
sensitive  to  pressure,  varying  in  size  from  a  simple  convexity  of  the  navel 
to  a  tumor  the  size  of  a  small  marble,  or  occasionally  larger,  and  globular 
or  irregular  in  shape  according  to  the  size  and  form  of  the  opening. 
Frequently  it  cannot  be  detected  at  times,  and  it  is  always  reducible 
unless  the  child  is  crying  or  straining.  Strangulation  very  rarely  occurs. 
The  hernia  consists  of  small  intestine  which  protrudes  through  a  por- 
tion of  the  umbilical  ring,  and  is  covered  by  the  abdominal  parietes. 
The  prognosis  is  almost  entirely  favorable.  The  majority  of  cases  will 
recover  spontaneously  if  such  causes  as  continuous  abdominal  disten- 
tion or  persistent  straining  efforts  be  removed.  Yet  as  it  is  possible  for 
the  hernia  to  persist,  and  in  view  of  the  fact  that  the  longer  the  opening 
remains  the  more  likely  is  this  to  happen,  every  case  should  receive 


HERNIA 


793 


treatment.  The  diagnosis  presents  no  difficulty.  A  large  serous  accum- 
ulation in  the  abdominal  cavity  could  distend  and  project  through  the 
centre  of  the  navel,  but  the  attending  symptoms  would  remove  all 
question.  Preventive  treatment  is  important.  A  firm  compress  should 
be  worn  under  the  abdominal  band  for  the  first  few  months,  and  all  con- 
ditions liable  to  produce  hernia  should  be  removed.  If  a  hernia  is 
present  it  should  be  kept  constantly  reduced  until  the  opening  in  the  ab- 
dominal wall  has  had  time  to  close.  Usually  it  is  quite  sufficient  to 
draw  the  skin  into  tw^o  folds,  one  on  each  side  of  the  hernia  and  meeting 
over  it;  holding  these  in  place  by  straps  of  adhesive  plaster  crossing  over 
the  navel,  or  by  a  broad  horizontal  band  of  adhesive  plaster  reaching  to 
the  lumbar  regions  (Figs.  260,  261).  Another  method  is  the  following: 
A  silver  quarter  of  a  dollar  is  laid  upon  the  adhesive  surface  of  a  piece 
of  rubber  adhesive  plaster  2  inches  square;  over  this  is  placed  the  broad 
strap  referred  to,  with  its  adhesive  surface  next  to  that  of  the  smaller 


Fig.    261. — Band   of   Adhesive    Plaster    over   an   Acquired    Umbilical   Hernia- 
The  Plaster  is  Tensely  Drawn  and  Applied  and  Fastened  over  the  Ribs  on  Both 
Sides,  so  that  a  Longitudinal  Fold  of  the  Abdominal  Wall  is  Drawn  over  the 
Hernia. 
(Hecker  and  Trumpp,  Atlas  of  Diseases  of  Children,  American  Translation,  Fig.  23,  p.  83.) 

piece.  After  reducing  the  hernia  and  pressing  the  sides  of  the  abdominal 
walls  slightly  together  the  band  is  applied  with  the  quarter  dollar 
directly  over  the  position  of  the  navel.  My  own  preference  is  for  a 
simple  adhesive  l)and  without  the  use  of  the  coin.  The  dressing  should 
be  worn  constantly,  changing  it  from  time  to  time  as  the  old  one  loosens. 
The  dressing  must,  of  course,  not  be  removed  during  the  bath.  Several 
months  are  required  before  the  opening  is  permanently  closed.  Occasion- 
ally the  plaster  produces  a  great  deal  of  cutaneous  irritation,  especially  in 
the  first  few  months  of  life.  The  employment  of  zinc  oxitle  plaster 
tends  to  avoid  this  (lifficulty.  When  the  irritation  is  obstinate,  treat- 
ment may  be  deferred  for  a  whih>  until  the  child  is  a  little  older;  or,  if 
the  hernia  is  very  small,  it  nuiy  be  possible  to  trust  the  cure  to  Nature. 
When  a  dressing  is  required  and  plaster  cannot  be  worn,  we  must  de- 
pend upon  a  closely  applied  banclage  of  woolen  material  or  webbing, 
although  this  is  less  satisfactory.  In  no  case  should  any  apparatus  be 
used  with  a  rounded  surface  which  pushes  the  hernia  inward.  The  pres- 
sure from  without  merely  serves  to  keep  the  umbilical  ring  open. 


794  THE  DISEASES  OF  CHILDREN 

Hernia  in  children  older  than  a  year  resists  mechanical  treatment 
obstinately.  Such  an  appliance  as  described  may  be  tried;  and  if  it 
seems  to  do  good  its  employment  must  be  persisted  in  for  months.  If 
cure  is  not  then  progressing,  a  radical  operation  is  indicated. 

2.  Inguinal  Hernia 

This  is  much  less  frequent  than  umbilical  hernia  in  the  first  few  weeks 
of  life,  but  more  common  when  developing  after  this  period.  As  in  the 
umbilical  affection,  it  may  be  congenital  or  acquired.  The  great  major- 
ity of  the  acquired  cases  depend,  however,  on  favoring  conditions  which 
are  congenital  in  nature;  viz.  a  patulous  state  of  the  funicular  process 
of  the  peritoneum  through  which  the  testicle  descends;  the  shortness 
and  straightness  of  the  canal,  and  the  width  of  the  inner  ring.  Omitting, 
then,  the  truly  acquired  hernia  of  later  childhood,  which  is  identical  in 
nature  with  that  of  adult  life,  and  less  often  seen,  we  may  divide  the 
hernias  of  infancy  into  (a)  congenital  hernia  of  the  tunica  vaginalis, 
in  which  the  funicular  process  of  the  peritoneum  is  completely  open  and 
the  intestine  descends  to  and  often  surrounds  the  testicle;  (b)  funicular 
hernia,  in  which  the  tunica  vaginalis  is  closed  above  the  testicle  and  the 
intestine  fills  the  funicular  process  down  to  this  closure,  the  intestine  in 
this  variety  not  enveloping  the  testicle;  (c)  the  encysted  or  infantile 
hernia,  a  rare  form  in  which  the  internal  ring  has  closed  but  the  intestine 
pushes  down  a  pouch  of  peritoneum  beside  this  or  into  the  patulous 
funicular  process  below  the  ring.  Except  for  the  differences  mentioned, 
which  are  purely  pathological,  these  various  forms  cannot  with  certainty 
be  distinguished  from  each  other  except  at  operation,  and  then  the 
matter  is  of  no  practical  moment. 

Etiology. — Apart  from  the  anatomical  causes  mentioned,  age  is  a 
strongly  predisposing  factor,  the  majority  of  cases  in  infancy  occurring 
in  the  1st  year  of  life,  but  sometimes  not  until  later,  and  sometimes  seen 
immediately  after  birth.  Heredity,  too,  plays  some  part.  The  great 
majority  of  instances  are  met  with  in  boys,  85  out  of  94  cases  reported  by 
Ashby  and  Wright^  being  in  this  sex.  Distention  of  the  abdomen  by 
gas,  excessive  crying  or  coughing,  straining  at  stool  the  result  of  diarrheal 
disturbances,  the  straining  on  urination  caused  by  excessive  phimosis  or 
urinary  concretions,  impairment  oL  the  general  health,  and  similar  con- 
ditions may  constitute  the  final  active  cause. 

Symptoms. — These  differ  little  from  those  of  adult  life.  The  rup- 
ture is  oftener  situated  on  the  right  side,  but  not  infrequently  is  double. 
The  contents  of  the  sac  are  much  the  same  as  in  the  adult.  They 
consist  usually  of  small  intestine  only,  perhaps  with  omentum;  while 
somethnes  the  cecum  and  vermiform  appendix  occupy  the  sac,  rarely 
Meckel's  diverticulum,  and  occasionally  an  ovary.  In  a  considerable 
number  of  cases  the  appendix  is  found  within  the  hernial  sac,  either 
alone  or  with  other  portions  of  the  intestinal  tract.  The  literature  of 
this  condition  has  been  reviewed  by  Jopson.^  Reduction  is  gener- 
ally easier  than  in  adult  cases,  as  the  hernia  is  usually  smaller  and  adhe- 
sions have  not  formed.  It  is  only  occasionally  that  a  large  rupture  fills 
the  scrotum  (Fig.  262). 

Prognosis. — -Thc^  prognosis  of  the  disease  is  favorable,  complete 
recovery  usually  following  the  early  application  of  a  suitable  truss;  or 

1  The  Dis.  of  Child.,  Amer.  Edit.,  1893,  136. 

2  Univ.  Med.  Magaz.,  1900,  Xlll,  94. 


HERNIA 


795 


if  this  does  not  succeed,  the  radical  operation  giving  excellent  results. 
Strangulation  is  comparativel}'  uncommon  in  early  life.  It  is  seen  oftener 
in  the  first  2  years  than  in  childhood  after  that  period.  Estor^  in  a 
study  of  207  cases  of  strangulation  in  infants  up  to  the  age  of  2  j-ears, 
estimates  that  the  likelihood  of  the  development  of  this  as  compared  with 
that  of  adults  is  only  in  the  ratio  of  1:131.  Strangulation  according  to 
Moynihan-  is  more  prone  to  occur  in  the  first  3  months  than  after  that 
period  during  the  1st  year.  Whitelocke-^  reported  2  cases  in  infants  of 
17  and  22  days  respectively. 

Diagnosis. — The  only  difficulty  in   diagnosis  is  in   distinguishing 
the  lesion  from  hydrocele,  the  two  conditions  often  closely  resembling 


Fig.  261i. — Large  Inguinal  Hernia. 
Infant  of  14  months,  in  the  Children's  Hospital  of  Philadelphia. 


each  other.  Hernia  is  usually  opaque  with  transmitted  light  and  hydro- 
cele translucent;  but  this  is  open  to  exceptions  and  hernias  may  also 
sometimes  appear  translucent,  if  bowel  only  is  present  and  is  distended 
by  gas  without  fecal  matter.  Hydrocele  is  tluU  on  percussion  and  reduces 
slowly  and  often  not  at  all.  Hernia  gives  an  impulse  on  coughing  and 
reduces  more  quickly  and  often  with  the  characteristic  gurgling  sound. 
The  difficulty  in  diagnosis  is  increased  by  the  fact  that  a  hydrocele  may 
occupy  tlu^  tunica  vaginalis  and  a  hernia  of  the  cord  be  situated  imme- 
diately above  this.  Strangulation  may  in  exceptional  cases  be  r(>adily 
confounded  with  severe  colic  unless  tli(>  possibility  of  tiiis  occurrence 
is  borne  in  mind  and  a  systematic  examination  made.     I  have  seen  this 

1  Rev.  de  chir.,  1902.  XXV,  215). 

»  Lancet,  1897,  II,  788. 

'  Brit.  .lour.  CliiM.  Dis.,  191:?,  X.  2.");i. 


796  THE  DISEASES  OF  CHILDREN 

error  made  in  a  child  of  less  than  a  year.  In  later  childhood  the  ordinary 
symptoms  of  hernia  develop,  and  the  diagnosis  presents  no  difficulty. 

Treatment. — This  is  very  satisfactory  in  that  the  majority  of  cases 
will  recover  completely  under  the  application  of  a  suitable  truss  and  the 
removal  of  the  exciting  causes.  A  truss  of  hard  rubber  or  a  skein  of 
woolen  yarn  must  be  worn  constantly,  and  the  mother  impressed  with  the 
importance  of  never  allowing  the  hernia  to  descend.  The  skin  under  the 
truss  must  be  kept  dry  and  clean  and  in  a  healthy  condition.  The  con- 
stant wearing  of  a  truss  will  often  cure  a  rupture  in  3  months  in  cases 
occurring  in  the  1st  year  of  life;  a  longer  time  is  requu'ed  if  treatment  is 
begun  after  this  period. 

When  the  use  of  a  truss  does  not  succeed  by  the  end  of  the  1st  year, 
and  in  every  case  where  the  hernia  is  found  irreducible  after  gentle 
efforts,  a  radical  operation  for  permanent  cure  must  be  employed.  This 
should  be  done  promptly  in  irreducible  cases  even  though  no  threatening 
symptoms  are  present.  It  has  also  been  recommended  to  close  the  open- 
ing of  the  sac  by  the  injection  of  paraffin  about  it. 

3.  Diaphragmatic  Hernia 

Omitting  hernias  of  this  nature  which  result  from  severe  trauma,  as 
from  wounds  of  the  diaphragm,  this  unusual  condition  is  generally 
congenital;  and  even  in  the  occasional  acquired  cases  seems  then  depend- 
ent upon  an  already  existing  congenital  defect  in  the  diaphragm.  The 
intestine,  and  often  other  viscera  as  well,  project  to  a  greater  or  less  degree 
into  the  thoracic  cavity  through  an  abnormal  opening  in  the  diaphragm. 
In  well-marked  cases  physical  examination  shows  the  stomach  and  a 
large  portion  of  the  intestine  in  the  pleural  cavity,  with  displacement  of  the 
lungs  and  heart  and  an  abnormal  sinking  in  of  the  abdominal  walls.  The 
percussion  note  in  the  thorax  is  tympanitic;  the  respiratory  murmur 
absent.  There  are  also  dyspnea,  cyanosis,  and  vomiting  and  other 
digestive  disturbances.  Often,  however,  no  diagnosis  is  made  until  at  a 
post-mortem  examination.  Occasionally  subjects  of  this  condition  live 
until  adult  years,  but  more  frequently  the  severity  of  the  symptoms  ter- 
minates life  in  the  1st  year,  or  death  follows  incarceration  or  strangula- 
tion with  the  usual  manifestations.  The  only  treatment  possible  is  to 
guard  against  incarceration  by  careful  diet  and  hygiene,  and  to  operate 
immediately  should  this  accident  occur. 

4.  Ventral  Hernia 

This  is  a  not  very  common  form  of  hernia.  It  consists  in  the  protru- 
sion of  a  small  portion  of  intestine  either  through  a  defect  in  the  median 
line  of  the  abdominal  wall  or  in  the  lumbar  region  {lumbar  hernia).  The 
former  is  always  small,  sometimes  multiple  and  is  usually  accompanied  by 
umbilical  hernia.  The  rare  lumbar  hernia  may  reach  a  much  greater 
size.  Treatment  in  either  case  is  very  similar  to  that  recommended  for 
umbilical  hernia. 

INTESTINAL  ULCERATION 

This  is  the  result  of  so  many  causes,  and  is  a  symptom  of  such  diverse 
conditions  that  no  more  than  a  mere  reference  can  be  made  to  most  of  the 
forms  in  this  connection,  only  a  few  being  treated  of  here  more  in  detail. 


INTESTINAL  ULCERATION  797 

(1)  Duodenal  Ulcer 

The  round  peptic  ulcer,  similar  in  nature  and  in  method  of  production 
to  that  occurring  in  the  stomach,  is  of  uncommon  occurrence  in  children, 
yet  distinctly  more  frequent  than  was  formerly  supposed.  Schmidt^ 
found  it  present  in  20  out  of  1109  autopsies  in  the  1st  year  of  life;  i.e. 
1.8  per  cent.;  and  in  17  out  of  2715  autopsies  in  children  from  the  2nd 
year  onward;  i.e.  0.6  per  cent.  In  a  previous  publication^  I  reported  2 
cases  and  collected  a  number  of  instances  occurring  in  medical  literature, 
and  Holt^  and  Veeder*  have  each  reviewed  the  subject  carefully.  The 
disease  is  oftenest  seen  in  atrophic  infants  in  the  1st  year  of  life.  It  occurs 
perhaps  most  frequently  in  the  new  born  and  is  then  a  cause  of  melena. 
The  ulcer  is  usually  single,  although  two  or  more  are  occasionally  seen; 
possesses  the  sharply  defined  edges  characteristic  of  gastric  ulcer;  and  is 
generally  situated  on  the  posterior  wall  of  the  duodenum  and  above  the 
papilla.  It  maj'-  involve  only  the  mucous  membrane,  or  may  extend  to 
the  serous  layer  and  may  even  perforate.  Gerdine  and  Helmholz,^  in 
reporting  11  personal  cases,  support  the  view  that  the  condition  may  be 
epidemic  and  is  dependent  upon  the  action  of  the  streptococcus  viridans. 

Symptoms. — In  a  large  proportion  of  cases  these  are  entirely  lack- 
ing, and  the  condition  is  purely  a  post-mortem  finding.  In  others  there 
may  be  a  sudden  fatal  collapse,  indicating  a  possible  concealed  hemor- 
rhage or  an  intestinal  perforation,  but  without  sufficient  data  to  render 
such  a  diagnosis  possible.  Melena  in  the  new  born  may,  as  stated,  be 
dependent  upon  duodenal  ulceration,  but  there  is  usually  no  possibility 
of  determining  this  with  certainty,  and  the  majority  of  cases  of  melena  are 
not  produced  in  this  way.  The  only  truly  suggestive  symptoms  indicat- 
ing duodenal  ulceration  are  hematemesis  and  the  passage  of  blood  by  stool. 
The  blood  may  be  in  large  amount  and  bright-red,  or  it  may  appear  as 
coffee-ground  vomiting  and  as  tarry  evacuations.  In  older  children 
there  maj'-  sometimes  be  pain  and  tenderness  in  the  region  of  the  duode- 
num just  below  the  liver  to  the  right  of  the  median  line;  but  this  is  an 
unusual  symptom.  In  a  number  of  instances  there  have  been  seen 
symptoms  suggesting  pyloric  stenosis,  depending  probably  upon  pyloro- 
spasm  produced  by  a  reflex  irritation  from  an  ulcer  just  below  the  pylorus. 
Such  cases  have  been  reported  by  Finney,*^  Torday^  and  others. 

The  prognosis  is  very  uncertain.  Death  may  result  promptly 
from  hemorrhage;  or  a  temporary  improvement  of  symptoms  may  be 
followed  by  relapse.  Recovery  seems  possible,  but  is  a  matter  not  sus- 
ceptible of  proof,  and  is  probably  not  of  frequent  occurrence. 

The  diagnosis  can  be  made  only  provisionally.  The  preponderance 
of  the  passage  of  blood  by  the  bowel  over  hematemesis  is  suggestive. 

Treatment. — This  consists  in  efforts  to  check  hemorrhage  or  to 
prevent  recurrence.  For  the  first,  trial  may  be  made  of  gelatine  and  of 
opinophrine  internally.  The  patient  must  be  at  absolute  rest,  and  the  diet 
of  the  lightest  and  most  unirritatingsort,  at  firstgiven  by  enema  only.  An 
ice-hag  may  b(!  placed  over  the  region  of  the  duodonum,  guarding  care- 
fully against  depression  if  the  patient  is  an  infant.  I'i  henioirliage  is 
severe  and  is  unchecked  by  other  measures,  or  if  symptoms  of  a  perforative 

»  Hcrl.  kliii.  Wocli.,  l<)i:i,  L,  mw. 

■  New  York  .Med.  .lour.,  1911,  S(«|)t.  1(>. 

3  Ainer.  Jour.  ])is.  Child.,  VM.i,  VI,  :W1. 

*  Auier.  .Jour.  Med.  Sci.,  1«»14,  C.XJAIII,  7(M). 

*  Amor.  Jour.  Dis.  Child.,  1<)1."),  X,  M)7. 

«  Proc.  Royal  Soc.  of  Med.,  l<)()S-<),  Sot-t.  for  Dis.  of  Child.,  (w. 
'  Jahrb.  f.  Ivinderh.,  1900,  LXlll,  503. 


798  THE  DISEASES  OF  CHILDREN 

peritonitis  develop,  exploratory  laparotomy  is  the  only  course  remaining 
open.  To  prevent  the  return  of  hemorrhage  the  diet  must  continue  light 
and  free  from  substances  of  an  irritating  nature,  such  as  spices  or  food 
containing  much  waste  material.  Over-exercise  must  be  avoided,  espe- 
cially such  as  would  produce  undue  strain  of  or  pressure  upon  the  abdom- 
inal region. 

The  ulceration  of  ileocolitis  is  a  verj^  common  condition  in  infancy. 
The  ulcers  are  very  abundant  and  of  sizes  varying  from  minute  erosions 
to  larger,  deeper  lesions.  Further  description  will  be  found  under  the 
heading  of  this  disease. 

Typhoid  ulcers  are,  as  a  rule,  not  nearly  so  common  or  so  large  in  early 
life  as  later.  They  may  sometimes,  however,  be  abundant  and  extensive 
even  at  this  period,  and  perforation  maj^  take  place.  (See  Typhoid  Fever, 
p.  390.) 

Syphilitic  ulceration  of  the  intestine  is  a  rare  occurrence  in  children 
and  infants.  It  is  the  result  of  gummatous  or  necrotic  alteration  affect- 
ing the  intestinal   canal. 


(2)  Tuberculous  Ulceration 
(Tuberculosis  of  the  Intestine) 

The  method  of  infection  of  the  intestines  by  tuberculosis  and  the 
frequency  of  this  have  already  been  described  under  the  heading  of 
Tuberculosis,  where  some  statistics  bearing  upon  the  subject  will  be  found 
(pp.  543,  546  and  557).  The  disease  may  be  primary  in  the  intestine, 
but  is  usually  secondary  to  lesions  in  the  lungs,  and  is  nearly  always  com- 
bined with  involvement  of  the  mesenteric  lymph-glands.  It  may  occur 
at  any  period  of  early  life,  but  is  most  frequent  in  early  childhood,  yet  less 
common  than  other  forms  of  tuberculosis  at  this  time. 

Pathological  Anatomy. — The  lesions  are  situated  chiefly  in  the 
small  intestine,  especially  the  ileum  near  the  ileocecal  valve;  although 
they  occur  to  a  less  extent  in  the  cecum,  colon,  jejunum,  and  the  appen- 
dix. The  serous  membrane  of  the  bowel  may  be  covered  by  tubercles  in 
acute  miliary  tuberculosis,  but  as  a  rule  the  lesions  as  discovered  at 
autopsy  are  of  an  ulcerative  nature,  situated  in  the  mucous  membrane  and 
submucous  layer.  Early  in  their  course  they  consist  of  miliary  nodules, 
soon  becoming  of  a  yellowish  color,  and  often  numerous  and  widespread. 
Some  of  these  break  down  and  form  small  erosions,  and  then  may  extend 
and  coalesce,  forming  large  ulcers  of  even  1  to  2  inches  (2.5  to  5  cm.) 
in  diameter.  The  number  of  these  larger  ulcers  is  usually  not  great. 
In  its  typical  form  the  tuberculous  ulcer  is  of  irregular  shape  with  uneven 
infiltrated  edges  which  project  above  the  level  of  the  surrounding  mucous 
membrane,  while  miliary  tubercles  cover  the  bottom.  The  largest 
diameter  is  usually  transverse  to  the  canal  of  the  intestine,  and  sometimes, 
in  elliptical  form,  the  ulcer  may  reach  nearly  or  quite  around  the  lumen. 
The  smaller  ulcers  show  a  loss  of  mucous  membrane  only;  the  larger  ones 
penetrate  the  submucous  tissue  as  well,  and  even  to,  or  sometimes  through, 
the  serous  layer.  If  the  case  is  long-continued  some  ulcers  exhibit  at 
autopsy  cicatricial  changes,  with  healing  of  the  lesion  and  consequent  con- 
traction of  the  intestine  at  this  position.  Perforation  into  the  peritoneal 
cavity  is  uncommon,  because  of  involvement  by  the  tuberculous  process  of 
the  peritoneum  adjacent  to  the  ulcer,  and  consequent  formation  of 
adhesions. 


INTESTINAL  HEMORRHAGE  799 

Symptoms. — These  are  far  from  characteristic,  especially  in  the 
early  stages.  Small  tuberculous  ulcers  of  the  intestine  frequently  produce 
no  symptoms  whatever  and  are  discovered  only  at  autopsy.  In  other 
instances  the  symptoms  are  those  of  ileocolitis.  In  such  cases  the 
possibility  of  the  lesions  being  tuberculous  may  be  suspected  from  the 
chronicity  of  the  case,  and  from  the  association  of  undoubted  evidences  of 
the  infection  elsewhere  in  the  body,  especiallj^  in  the  lungs.  The  stools 
are  liable  to  be  more  watery  in  character  than  in  ileocolitis,  offensive, 
and  to  contain  more  or  less  blood,  especially  in  older  children.  Abdom- 
inal distention  and  tenderness  may  be  present;  there  is  irregular  fever; 
wasting  is  often  great;  anemia  and  debility  decided ;  appetite  is  diminished ; 
the  pulse  weak,  and  the  abdomen  tympanitic.  In  advanced  cases  the 
symptoms  of  tuberculous  peritonitis  are  often  present  also,  or  deep 
palpation  may  reveal  enlargement  of  the  mesenteric  l3^mphatic  glands. 
Microscopic  examination  may  sometimes  show  tubercle  bacilli  in  the 
stools;  yet  the  possibility  of  these  coming  from  the  swallowing  of  tubercu- 
lous sputum  must  not  be  forgotten. 

Course  and  Prognosis.^ — -The  disease  may  run  an  irregular  course 
and  last  for  months,  with  a  constantly  increasing  loss  of  health,  or  with 
temporary  periods  of  improvement,  diarrhea  perhaps  alternating  with 
constipation.  Although  recovery  is  probably  possible  it  is  certainly  very 
uncommon,  and  the  majority  of  patients  with  the  disease  gradually  fail 
in  health  and  die  from  exhaustion,  often  with  a  terminal  marantic  edema. 
In  other  cases  death  may  occur  from  some  complication,  such  as  profuse 
hemorrhage,  peritonitis,  or  tuberculosis  of  some  other  region. 

Diagnosis.- — ^This  depends  chiefly  upon  the  association  of  chronic 
intestinal  derangement  with  tuberculosis  elsewhere  in  the  body,  the 
very  slow  development  of  symptoms  at  the  beginning,  and  the  discover}^ 
of  tubercle  bacilli  in  the  feces.  Acute  ileocolitis  has  a  more  sudden  onset 
and  a  shorter  course,  and  the  chronic  form  gives  often  the  history  of  an 
earlier  acute  attack.  Hemorrhage  of  considerable  size  suggests  tubercu- 
losis rather  than  ileocolitis. 

Treatment. — This  can  be  only  symptomatic.  Pain  is  to  be  re- 
lieved by  hot  applications  to  the  abdomen,  such  as  poultices  or  turpentine 
stupes,  and  if  necessary  by  the  internal  administration  of  opiates.  For 
the  diarrhea  bismuth  and  tannic  acid  preparations  can  be  given,  with  or 
without  opium.  The  diet  must  be  sustaining  but  unirritating.  Alcoholic 
stimulants  are  often  required. 

INTESTINAL  HEMORRHAGE 

As  this  symptom  is  referred  to  in  various  sections  treating  of  s|)ecial 
diseases  it  will  be  mentioned  here  but  briefly.  Strictly  speaking  intes- 
tinal hemorrhage  indicates  blood  arising  from  the  intestine  itself,  but 
more  ))roadly  the  term  may  be  used  to  include  the  discharge  of  blood  from 
the  rectum,  whatever  its  source.  Thus  in  severe  epistaxis  the  blood  may 
be  swallowed  and  later  passed  from  the  bowel;  and  hemorrliage  origi- 
nating in  the  stomacii  may  r(>veal  itself  in  like  manner.  Melcna  is  the 
title  applied  to  one  of  the  earli(>sl  forms  of  iiitcv'^tiiial  lieniorrhage  seen 
(see  Melcna,  p.  2()()),  the  blood  being  usually  altered  in  cliaracler  and  ap- 
pearing as  a  tarry  substance  in  the  stools.  In  some  cas(>s  this  depends 
upon  ulceration,  especially  of  the  (hiodeinim.  Another  form  of  intest- 
inal hemorrhage  occurring  very  early  in  life  is  that  observed  in  the  hemor- 
rhagic disease  of  the  new  born  (p.  2()4),  in  which  the  loss  of  lilood  may  be 
very  considerable.     Intestinal  hemorrhage  is  also  seen  in  the  ulceration 


800  THE  DISEASES  OF  CHILDREN 

of  typhoid  fever,  intussusception  and  ileocolitis,  the  last  two  exhibit- 
ing usually  streaks  of  blood  merely.  The  hemorrhage  of  tuberculous 
ulceration  may  be  of  the  same  streak-like  character  or  may  be  of  consider- 
able size  and  even  large  enough  to  be  fatal.  Hemorrhage  from  the  bowel 
may  occur  in  leukemia  or  pernicious  anemia,  is  a  common  symptom  of 
hemorrhagic  purpura,  and  is  sometimes  seen  in  infantile  scurvy.  Bloody 
mucus  or  a  few  drops  of  blood  with  the  stool  are  encountered  in  fissure 
of  the  anus  and  even  of  simple  intense  congestion  of  the  intestinal  mucous 
membrane,  while  ulceration  of  the  rectum  som.etimes  produces  a  con- 
siderable loss  of  blood,  as  may  the  hemorrhoids  which  occasionally  occur 
in  early  life.  Sometimes  the  hemorrhage  depends  upon  the  presence 
of  a  rectal  polyp,  or  of  small  papillomatous  growths.  Apart  from  these 
conditions  the  appearance  of  blood  in  streaks,  or  even  to  the  amount 
of  a  fluidram  or  more,  frequently  attends  in  infancy  the  injury  to  the  rectal 
mucous  membrane  done  by  the  passing  of  a  large,  hard  fecal  mass. 

The  treatment  of  intestinal  hemorrhage  depends  entirely  upon  the 
cause  and  is  referred  to  under  the  separate  headings  where  these  causes 
are  discussed, 

APPENDICITIS 

This  title  has  in  recent  years  supplanted  the  older  ones  of  typhlitis, 
perityphlitis,  and  the  like,  these  conditions  now  being  attributed  in- 
variably to  a  primary  disease  of  the  appendix.  Although  abscess  in 
the  cecal  region  had  been  recognized  at  a  much  earlier  date,  the  first 
recorded  case  proven  to  have  been  disease  of  the  appendix  appears  to 
have  been  that  reported  by  Mestivier  in  1759  (Deaver).^ 

Etiology. — The  disease  may  occur  at  any  period,  yet  it  is  most 
frequent  in  early  and  middle  life,  being  commonest  between  10  and  30 
years  (Kelly  and  Herndon).^  It  is  distinctly  less  frequent  under  10 
years  of  age.  Hawkins^  in  224  cases  of  all  ages  found  only  26  in  children 
from  5  to  10  years.  McCosh^  in  1000  operative  cases  of  appendicitis  at 
all  ages  recorded  17  in  the  first  5  years  of  life,  51  at  from  5  to  10  years, 
and  85  at  from  10  to  15  years;  and  Maguire^  in  104  collected  cases  in 
children  found  3  under  3  years;  47  from  3  to  8  years;  and  54  from  9  to  14 
years.  Writing  in  1901,^  I  was  able  to  collect  but  14  cases  from  medical 
literature  occurring  in  the  first  2  years  of  life,  to  which  was  added  a 
15th  personal  case  in  an  infant  of  3  months.  Of  the  reported  cases  2 
(Pollard^  and  Goyens*)  were  in  infants  of  6  weeks  of  age.  Other  scat- 
tered instances  of  the  disease  in  infancy  have  been  published  since 
then,  one  by  Remsen^  in  an  infant  of  16  days,  and  Abt^*^  has  collected  in 
all  80  cases  of  the  disease  in  the  first  2  years  of  life.  One  of  the  youngest 
recorded  cases  appears  to  have  been  that  of  Gloniger  (Kelly  and  Herndon)  ^^ 
in  an  infant  operated  upon  successfully  when  but  41  hours  old;  while 

1  Treatise  on  Appendicitis,  1900,  18. 

2  The  Vermiform  Appendix,  1905,  452. 

^  Dis.  of  the  Vermiform  Appendix,  1895,  62. 
^  Journ.  Amer.  Med.  Assoc,  1904,  Sept.  24. 

5  Virginia  Med.  Semi-month.,  1898-99,  III,  400. 

6  Univ.  of  Pa.  Med.  Bull.,  1901,  Oct. 
^Lancet,  1895,  I,  1114. 

8  Gaz.  med.  Beige,  1900,  XII,  133. 

9  Annals  of  Surg.,  1912,  LVI,  911. 

"  Arch,  of  Fed.,  1917,  XXXIV,  641. 
n  hoc.  cit.,  453. 


APPENDICITIS  801 

Jackson^  records  an  instance  which  he  regards  as  prenatal,  found  in  an 
infant  dying  of  metaUic  poisoning  when  40  hours  old. 

More  males  appear  to  be  attacked  than  females,  although  some 
statistics  are  at  variance  on  this  point.  In  500  cases  in  children  up  to  15 
years  seen  by  H.  C.  Deaver-  there  were  315  males  and  185  females. 
Digestive  disturbances,  especially  constipation  or  diarrhea,  are  perhaps 
the  most  frequent  predisposing  causes  in  children.  Infectious  diseases 
sometimes  predispose.  This  is  especially  true  of  lacunar  angina, 
although  observed  also  in  typhoid  fever,  grippe,  rheumatism,  and  pneu- 
monia. Trauma  seems  sometimes  to  be  a  cause,  and  heredity  is  also 
not  without  influence,  there  being  a  distinct  tendency  for  more  than  one 
member  of  a  family  to  be  attacked.  Although  foreign  bodies,  such  as 
fruit  seeds,  are  sometimes,  and  fecal  concretions  often,  found  in  the  dis- 
eased appendix  there  seems  little  reason  to  believe  that  these  have  any 
etiological  relationship  except  in  occasional  instances. 

As  to  the  direct  exciting  cause  little  positive  is  known,  except  that 
anything  which  produces  narrowing  of  the  lumen  of  the  appendix  may 
occasion  retention  of  secretion,  and  be  followed  by  congestion  and  by 
wandering  of  bacteria  from  the  surface  of  the  mucous  membrane  into 
the  tissue  of  the  wall  of  the  organ.  The  germs  found  are  most  frequently 
streptococci  and  especially  colon  bacilli. 

Pathological  Anatomy. — The  various  divisions  of  appendicitis, 
based  upon  the  pathological  lesions  and  clinical  symptoms,  are,  for  the 
most  part,  only  steps  in  the  same  anatomical  process.  As  a  result  of, 
perhaps,  kinking  of  the  appendix  or  other  cause  obstructing  its  lumen, 
congestion  takes  place  and  inflammation  of  the  mucous  membrane  fol- 
lows with  redness  and  swelling,  especially  of  the  lymphatic  follicles 
which  are  extremely  numerous  in  this  organ,  and  which,  in  fact,  make  it 
resemble  the  tonsil  to  some  extent.  A  small-celled  infiltration  accompan- 
ied by  edema  occurs  which,  with  bacteria,  may  penetrate  even  to  the 
serous  layer.  The  appendix  is  thickened,  stiff,  and  cylindrical  and  may 
be  much  distended  by  the  secretion.  A  fibrinous  inflammation  of  the 
serous  layer  may  produce  a  thick  deposit  of  fibrin  on  it  and  on  the  adja- 
cent adherent  coils  of  intestine.  The  condition  produced  is  that  de- 
nominated in  its  milder  form  catarrhal  appendicitis  or  appendicitis 
simplex,  or  diffuse  appendicitis  when  more  severe.  Entire  resolution  may 
take  place,  but  often  some  degree  of  overgrowth  remains,  causing  more 
or  less  constriction  of  the  appendix,  or  the  formation  of  adhesions.  On 
the  other  hand,  the  process  may  advance  further  and  may  give  rise  either 
to  a  chronic  inflammatory  condition,  or  to  suppuration.  If  bacteria  have 
penetrated  deeply  and  in  large  numbers,  and  the  celhilar  infiltration  and 
edema  have  been  extensive,  pus  is  produced  in  the  wall  of  the  aj^pondix 
{suppurative  appendicitis)  and  penetrates  into  its  lumen,  filling  and  dis- 
tending this  with  an  offensive,  purulent  material  which  may  sometimes 
discharge  itself  through  the  natural  opening  into  the  bowel.  More 
frequently,  however,  the  pus  makes  its  way  also  toward  the  serous  layer 
and  penetrates  this  (perforative  appendicitis).  This  promptly  pro(hu"es 
a  general  septic  peritonitis,  unless  the  perforation  is  shut  off  by  adhesions. 
[n  the  latter  event  a  locaHzed  peritonitis  with  perityphHtic  abscess  de- 
velops, which  may  finally  find  exit  by  eroding  into  the  bowel  or  in  other 
directions,  but  is  especially  prone  to  burst  into  the  peritoneal  cayitj'. 
In  the  more  intense  forms  of  suppurative  inflammation,  where  the  circu- 

1  Amor.  Jour.  Mod.  Soi.,  1904,  CXXVII,  710. 

2  Jour.  Anier.  Med.  .Vssoc,  1910,  LV,  2198. 
51 


802  THE  DISEASES  OF  CHILDREN 

lation  is  entirely  cut  off  by  the  pressure  of  the  exudate,  there  develops 
rapidl}^  a  gangrenous  condition  of  all,  or  oftener  of  the  tip,  of  the  appendix 
{gangrenous  appendicitis) ,  which  is  followed  by  perityphlitic  abscess  if 
adhesions  form,  or  frequentl}^  by  a  general  peritonitis  from  rupture. 

In  cases  of  chronic  appendicitis  the  appendix  remains  thickened  and 
firm  perhaps  with  constrictions  at  one  or  more  portions,  as  a  result  of 
which  the  tip  may  be  distended  with  pus  or  with  a  watery  fluid,  while 
numerous  adhesions  may  connect  it  with  other  organs.  A  sudden  severe 
acute  attack  may  at  any  time  develop  upon  the  basis  of  the  chronic  dis- 
turbance. In  other  cases,  especially  infrequent  in  early  life,  as  a  result 
of  repeated  acute  attacks  a  progressive  involution  of  the  appendix  takes 
place,  with  atroph}^  of  the  lymph-nodules  and  the  mucous  glands,  until 
the  organ  is  much  shrunken  {obi iterative  appendicitis). 

Symptoms. — These  are  sometimes  verj'-  striking;  sometimes  recog- 
nized only  with  difficulty  and  uncertainty.  In  some  instances  they  pro- 
gress slowly  and  with  no  constitutional  involvement;  in  others  perfora- 
tion with  a  septic  peritonitis  comes  almost  as  out  of  a  clear  sky. 

Catarrhal  appendicitis  may  be  so  mild  that  it  is  not  recognized  at  all 
and  is  supposed  to  be  a  mere  digestive  disturbance.  In  other  cases 
the  symptoms  are  more  positive.  In  general  this  form  of  the  disease 
develops  as  a  primary  affection  or  consecutive  to  some  digestive  dis- 
order, and  is  ushered  in  by  colicky  pain  in  the  right  iliac  fossa  or  else- 
where in  the  abdomen,  this  constituting  the  principal  symptom,  With 
this  are  often  combined  nausea,  vomiting,  moderate  fever  of  100°  to 
102°  F.  (37.8°  to  38.9°  C),  loss  of  appetite,  coated  tongue,  and  consti- 
pation or  sometimes  diarrhea.  All  these  vary  with  the  severity  of  the 
case.  Examination  reveals  tenderness,  increased  resistance  in  the  cecal 
region,  and  often  in  1  or  2  days  an  induration  which  can  be  discovered 
by  palpation.  Often,  too,  when  there  is  a  plastic  exudate  upon  the  ser- 
ous surface  of  the  appendix  and  the  neighboring  parts,  a  distinct  tumor 
can  be  palpated.  If  the  patient  is  not  confined  to  bed  the  manner  of 
walking  is  suspicious,  the  child  leaning  forward  and  keeping  the  right 
thigh  slightly  flexed  toward  the  abdomen.  When  in  bed  the  patient  lies 
on  the  back  with  the  right  thigh  partially  flexed. 

Suppurative  appendicitis  is  marked  by  the  evident  constitutional 
involvement,  the  rise  of  pulse-rate  and  perhaps  of  temperature,  the 
appearance  of  the  face,  and  other  symptoms  pointing  toward  a  moderate 
degree  of  septic  poisoning.  These  symptoms  maj'  develop  with  great 
rapidity  after  some  days  of  manifestations  of  a  mild  character.  In  other 
cases  suppurative  appendicitis  is  present  almost  from  the  beginning, 
the  onset  is  violent  and  acute,  the  fever  more  marked,  vomiting  trouble- 
some, the  pulse  rapid  and  pain  decided.  These  s,ymptoms  may  continue 
for  several  days  or  they  ma}^  subside  promptly  and  lead  to  the  conclu- 
sion that  recovery  is  about  to  occur.  Then  in  from  2  to  4  days  from  the 
onset  perforation  may  take  place. 

The  symptoms  of  suppurative  appendicitis  vary,  whether  with  or 
without  perforation.  The  inflammaton  may  not  pass  beyond  the  serous 
wall  of  the  appendix,  and  produce  only  moderate  distension  of  the  lumen 
of  the  organ,  and  no  extensive  induration  develops.  In  those  non- 
perforative  cases  in  which  a  localized  plastic  peritonitis  also  occurs,  a 
very  decided  tumor  can  be  detected  on  palpation.  Fever  may  continue 
or  may  subside,  and  the  symptoms  are  less  severe  than  in  the  cases  in 
which  a  walled-in  abscess  forms  about  the  appendix.  In  these  latter 
vomiting  tends  to  persist,  tenderness  and  resistance  are  decided,  pain  is 


APPENDICITIS  803 

variable  but  usually  severe,  and  tympanites  is  common.  The  rapidity 
of  the  development  of  suppurative  appendicitis  varies  greatly.  In  some 
cases,  as  stated,  the  course  is  rapid  from  the  beginning  and  in  2  to  3 
days  undoubted  abscess  can  be  discovered.  In  others  the  earty  mani- 
festations are  all  mild  and  the  evidences  of  abscess  develop  only  after 
a  number  of  days  and  are  vague.  In  still  others  the  early  symptoms  may 
be  severe  and  be  followed  by  a  period  of  comparative  quiescence,  lasting 
several  days  or  even  weeks  and  then  the  local  and  constitutional  evidences 
of  the  formation  of  pus  appear. 

The  constitutional  symptoms  of  suppurative  appendicitis  depend 
not  so  much  upon  the  local  accumulation  of  pus  as  upon  the  degree  of 
septic  absorption  which  takes  place.  The  temperature  is  subject  to  great 
variations  in  different  cases  and  is  not  characteristic.  Often  the  devel- 
opment of  abscess  is  marked  by  a  progressive  increase  of  fever ;  while  on 
the  other  hand  the  temperature  may  remain  normal  or  nearly  so  even  in 
cases  which  are  clearly  septic.  The  pulse  becomes  rapid  and  weak  and 
the  general  sensations  and  appearance  of  illness  increase  in  proportion 
to  the  degree  of  septic  absorption  occurring. 

Perforation  into  the  peritoneal  cavity  may  take  place  from  a  gan- 
grenous appendicitis  which  has  formed  no  adhesions,  or  from  a  peri- 
appendicular abscess  which  has  finally  burst  the  restraining  wall.  It  is 
characterized  by  the  occurrence  of  vomiting,  or  an  increase  of  this  if 
alread}^  a  symptom;  severe  abdominal  pain;  and  profound  collapse 
with  the  usual  signs  of  rapid  feeble  pulse,  shallow  respiiation,  and  fall 
of  temperature.  The  expression  of  the  face  is  anxious  and  pinched, 
cold  perspiration  occurs,  the  abdomen  is  extremely  tympanitic,  and 
the  liver-dullness  much  diminished.  Death  may  take  place  without  any 
reaction,  or  the  temperature  may  rise  rapidly  even  to  hyperpyrexia  and 
the  symptoms  of  septic  peritonitis  develop.  The  signs  at  this  period  may, 
however,  be  very  deceptive,  especially  in  children,  there  being  sometimes 
only  a  moderate  depression  of  temperature,  with  apparent  improvement 
in  the  general  symptoms  attending  the  beginning  of  septic  poisoning. 

The  symptoms  of  gangrenous  appendicitis  are  ver}^  misleading  from 
the  beginning.  The  early  ones  are  not  characteristic  and  are  often  no 
more  severe  than  those  of  catarrhal  appendicitis.  Suddenly,  after  a 
few  days  illness,  perforation  takes  place  with  the  symptoms  of  this  as 
described.  In  other  cases  of  gangrene  the  local  manifestations  are  severe 
from  the  onset  with  unusual  tenderness,  pain  and  resistance  of  the  ab- 
dominal walls. 

Appendicitis  in  infancy  exhibits  symptoms  which  are  liable  to  be 
very  misleading,  owing  to  the  inability  to  determine  with  exactness  the 
existence  or  position  of  pain  and  tenderness.  Doul)tless  many  cases  are 
entirely  overlooked  at  this  age.  The  disease  may  exhibit  a  slow  or 
sudden  onset,  troublesome  vomiting,  diarrhea  or  constipation,  more  or 
less  fever,   and   finally  peritonitis. 

Recurrent  and  Chronic  Appendicitis. — There  is  a  very  decided  liability 
to  the  occuirence  of  rep(>ated  attacks  of  acute  appendicitis.  This 
depends,  doul)tless,  on  the  ixM'sistence  of  kinking  or  narrowing  of  the 
tube,  or  on  other  causes  wliich  determined  the  first  attack  or  which 
develop  as  a  result  of  this.  Among  such  causes  may  be  the  I'em.-iining 
of  small,  infected  foci  which  at  any  time  pi-e('ipitat(>  an  acute  infl:ininKi-» 
tion.  Such  recurrences  may  finally  lead  to  a  sever(>  and  fatal  jippendi- 
citis;  or  the  disposition  to  them  may  at  last  disapp(>ai',  jierhaps  through 
obliterative  inflammation  of  the  appendix.     It  is  a  mistake.  ho\\('V(M-, 


804  THE  DISEASES  OF  CHILDREN 

to  assume  that  recurrences  must  necessarily  come  after  the  first  attack. 
Hawkins^  estimates  the  habihty  to  recurrence  as  at  least  23.6  per  cent, 
as  shown  in  the  analysis  of  250  patients  of  all  ages.  Fitz^  found  it  in  11 
per  cent,  in  an  earlier  series  of  collected  cases,  but  in  44  per  cent,  of  72 
cases  seen  by  him  at  a  later  period. 

This  condition  of  recurring  attacks  may  be  regarded  as  one  of  the 
forms  of  chronic  appendicitis.  In  other  instances  the  attacks  are  more 
frequent  and  so  little  marked  that  their  nature  is  not  recognized,  and  they 
are  regarded  as  evidences  of  acute  indigestion,  until  examination  dis- 
covers the  existence  of  an  induration.  In  still  other  cases  the  disturb- 
ances are  more  of  the  nature  of  a  chronic  indigestion  with  poor  or  irregu- 
lar appetite,  constipation  and  other  indefinite  digestive  symptoms,  and 
general  poor  health.  Pain  may  be  very  frequent  and  in  some  cases 
nearly  constant;  or  may  be  brought  on  only  by  fatigue.  It  may  be 
located  in  the  appendicular  region  or  be  more  diffuse.  Some  cases  of 
repeated  attacks  of  vomiting  of  the  recurrent  type  probably  owe  their 
origin  to  actual  appendicitis.  The  frequency  of  this  has  been  maintained 
especially  by  Comby.^ 

In  view  of  the  importance  of  a  prompt  diagnosis  of  appendicitis  and 
the  great  difficulty  in  recognizing  the  disease  in  many  instances,  a  fuller 
consideration  of  the  individual  symptoms  is  of  advantage. 

Abdominal  Pain. — This  varies  greatly  in  intensity;  from  severe 
suffering,  either  continuous  or  often  occurring  in  paroxysms  with  inter- 
vals of  nearly  complete  or  entire  comfort,  to  pain  so  slight  that  it  is 
hardly  noticed  by  the  child  or  is  more  of  the  nature  of  an  uncomfortable 
sensation.  The  mildest  cases  have  but  little  pain  and  the  severe  ones 
suffer  much  from  it;  but  this  is  true  only  to  a  limited  extent,  since 
serious  cases  sometimes  have  but  little  suffering  even  when  abscess  is 
forming  or  a  short  time  before  perforation  occurs.  The  pain  is  often  at 
first  diffuse  but  later  usually  confines  itself  more  to  the  right  iliac  fossa. 
To  this  there  are  many  exceptions,  and  pain  is  referred  to  other  regions 
of  the  abdomen,  not  infrequently  the  umbilicus  or  the  epigastrium, 
and  sometimes  elsewhere.  When  it  is  in  the  region  of  the  bladder  and 
attended  by  symptoms  of  vesical  irritability,  as  is  often  the  case,  it 
may  readily  lead  to  mistakes  in  diagnosis.  Sometimes  there  is  pain 
during  or  before  evacuation  of  the  bowels,  and  in  other  cases  it  is  pro- 
duced by  traction  upon  the  testicle  or  spermatic  cord.  On  the  occurrence 
of  perforation  there  is  usually  a  sudden,  very  severe,  and  more  diffuse 
abdominal  pain. 

Tenderness.— This,  like  the  pain,  is  far  from  uniform  and  depends 
to  a  certain  extent  upon  the  severity  of  the  case,  being  but  slight  in 
catarrhal  cases  of  the  milder  form.  The  occurrence  of  periappendicular 
inflammation  is  attended  by  increasing  tenderness,  and  when  abscess 
forms  tenderness  is  very  great.  The  situation  of  the  sensation  is  usually 
in  the  right  iliac  fossa,  most  marked  at  McBurney's  point,  about  midway 
between  the  umbilicus  and  the  anterior-superior  iliac  spine;  yet  owing  to 
the  length  of  the  appendix  and  its  more  variable  position  in  children,  the 
chief  tenderness  may  be  situated  deeper  in  the  pelvic  cavity,  and  then  is 
perhaps  recognized  only  on  rectal  examination ;  or  may  be  found  higher 
in  the  abdomen  than  in  adults  or  even  in  the  left  iliac  region. 

Increased  Resistance  of  the  Abdominal  Walls. — This  goes  hand  in  hand 

^Loc.  cit.,  11.3. 

2  Boston  Med.  and  Surg.  Jour.,  1890,  CXXII,  619. 

3  Arch,  de  med.  des  enf.,  1910,  Xlil,  401. 


APPENDICITIS  805 

with  tenderness  and  is  very  characteristic.  It  is  nearly  always  present 
even  in  the  mildest  cases;  and  when  tenderness  is  severe  is  so  marked 
that  a  satisfactory  examination  cannot  be  made  through  the  abdominal 
walls. 

Induration  or  Tumor. — In  the  milder  cases  of  catarrhal  appendicitis 
there  is  no  tumor,  but  only  a  thickened  appendix  which  palpation  may 
reveal.  The  rapidly  gangrenous  cases  likewise  may  exhibit  no  tumor. 
On  the  other  hand,  tumor  is  present  when  the  lumen  of  the  appendix 
is  distended  by  pus  or  when  periappendicular  inflammation  occurs; 
whether  this  latter  is  purulent  or  merely  plastic  in  nature.  Bimanual 
palpation  with  one  hand  in  the  loin  often  aids  in  the  examination.  When 
tenderness  is  marked  it  is  possible  that  the  tumor  can  be  detected  only 
by  rectal  examination.  This  should  always  be  practised  in  doubtful 
cases,  comparing  with  the  finger  in  the  bowel  the  condition  of  the  two 
iliac  regions.  Yet  palpation  of  any  sort  must  always  be  done  with  great 
gentleness,  bearing  in  mind  the  danger  of  rupturing  a  periappendicular 
abscess.  Percussion  also  is  of  aid  in  recognizing  the  tumor  by  the 
dullness  of  the  sound  produced.  It  should  be  done  gently  to  avoid 
causing  suffering.  The  size  of  the  tumor  varies  greatly.  In  cases  of 
purulent  perityphlitis  the  abscess  which  forms  sometimes  reaches  large 
dimensions.  The  position  of  the  induration  or  abscess  varies  with  that 
of  the  appendix.  Like  the  pain,  it  is  oftenest  in  the  right  iliac  region, 
but  may  frequently  be  deeper  in  the  pelvis,  or  occasionally  below  the 
liver  or  in  the  loin.  The  length  of  the  appendix  in  children,  and  the  fact 
that  it  is  usually  the  tip  of  the  organ  which  is  the  seat  of  the  abscess- 
formation,  occasion  great  variation  in  the  position  of  the  induration. 

Tympanites. — This  is  not  a  pronounced  sign  in  uncomplicated 
appendicitis.  When  decided  it  is  an  evidence  of  suppurative  appendicitis, 
probably  with  a  mild  grade  of  peritonitis.  When  very  great,  with  disap- 
pearance of  hepatic  dullness,  it  indicates  perforation. 

Nausea  and  Vomiting. — These  are  symptoms  seldom  entirely  absent 
except  in  the  very  mild  cases,  but  they  are  prone  to  subside  after  the 
first  day  or  two.  In  the  severer  and  rapidly  developing  attacks  vomiting 
may  be  troublesome  and  persistent.  Yet  in  many  suppurative  cases 
vomiting,  like  other  acute  symptoms,  may  lessen  or  disappear  after  the 
first  few  days,  perhaps  to  return  in  force  as  the  indication  of  the  occur- 
rence of  a  perforation.  Stcrcoraceous  vomiting  is  an  evidence  of  abso- 
lute paralysis  of  peristalsis,  such  as  is  seen  when  widespread  peritonitis 
develops. 

Bowel  Movements. — The  condition  of  the  stools  is  of  importance  in 
most  cases.-  Diarrhea  by  no  means  excludes  appendicitis  in  chiklren, 
in  whom  it  is  more  likely  to  occur  than  in  adults.  Generally,  however,  in 
severe  cases,  whether  catarrhal  or  suppurative,  there  is  more  or  less 
paralysis  of  peristalsis,  and  constipation  is  decided  and  sometimes  abso- 
lute; and  this  is  true  of  the  instances  of  perforation  also. 

Tcnipernture. — Fever  is  so  extremely  variable  that  few  conclusions  can 
be  drawn  from  it.  The  mildest  cases  exhibit  little  or  no  elevation  of 
temperature  above  a  sub-febrile  degree.  Often  there  is  some  fever  at 
the  onset  which  may  soon  subside.  In  the  severer  attacks  fever  is  liable 
to  continue  and  reach  a  higher  degree  than  in  mild  ones,  although  in 
septic  cases  the  temperature  may  sometimes  remain  only  slightly  elevated. 
It  is  of  frequent  occurrence  for  the  temperature  to  fall  to  nearly  normal 
in  patients  who  are,  in  fact,  not  improving,  but  developing  abscess.  A 
perforation  may  occur  without  premonitor}-  return  of  fever;  or  renewed 


806  THE  DISEASES  OF  CHILDREN 

rise  of  temperature  may  indicate  a  rapid  abscess-formation.  In  fact, 
no  reliable  deductions  can  be  based  upon  the  elevation  of  temperature. 

Blood. — The  examination  of  the  blood  is  sometimes  a  most  valuable 
aid  in  the  study  of  this  disease.  A  rapid  increase  of  leucocytes  to  20,000 
or  30,000  per  c.mm.,  particularly  of  the  polymorphonuclear  cells,  com- 
bined with  the  presence  of  other  suggestive  symptoms,  is  often  an  indica- 
tion that  the  appendicitis  is  of  a  suppurative  type.  A  diminution  of  a 
leucocytosis  previously  present  is  a  favorable  indication,  if  attended 
by  an  improvement  in  the  general  and  local  manifestations.  On  the 
other  hand,  little  if  any  increase  of  the  leucocytes  is  an  equivocal  sign. 
It  may  be  present  in  catarrhal  appendicitis  or,  conversely,  in  serious 
fulminating  suppurative  cases.  The  presence  of  a  low  leucocyte  count 
with  severe  general  symptoms  is  a  bad  indication.  If  the  symptoms  are 
severe,  the  higher  the  leucocyte-count  and  the  greater  the  proportion 
of  the  polymorphonuclear  cells  the  better  is  the  prognosis. 

Pulse. — The  pulse  at  first  is  accelerated  only  in  proportion  to  the 
degree  of  fever,  or  sometimes  is  slower  than  normal.  If  septic  symptoms 
develop,  and  especially  if  perforation  occurs,  the  pulse  becomes  rapid, 
weak  and  compressible. 

Genito-urinary  Symptoms. — These  are  sometimes  decided.  The  urine 
is  scanty  and  not  infrequently  contains  albumin.  Irritabihty  of  the 
bladder  is  sometimes  great  and  may  easily  be  a  misleading  symptom.  An 
acute  nephritis  may  develop. 

Course  and  Prognosis. — The  course  of  catarrhal  appendicitis 
depends  upon  the  severity  of  the  inflammation.  In  the  milder  cases  the 
fever,  pain  and  vomiting  disappear  in  1  or  2  days,  and  at  about  the  same 
time  a  shghtly  indurated  appendix  may  be  felt.  The  total  duration  is  a 
week  or  less,  although  sometimes  a  longer  interval  elapses  before  the 
conditions  disappear.  In  the  more  severe  instances  the  initial  fever  and 
general  symptoms  last  somewhat  longer,  and  the  indurated  mass  felt  is 
very  distinct;  but  improvement  is  not  long  delayed,  and  by  the  end  of  a 
week  convalescence  is  well  estabhshed,  although  induration  and  shght 
tenderness  may  last  a  somewhat  greater  time.  If  the  inflammation  does 
not  advance  to  a  suppurative  condition  the  prognosis  of  the  individual 
attack  is  always  good,  except  for  the  great  tendency  to  recurrence  on  one 
or  several  occasions,  on  any  one  of  :sdiich  a  dangerous  suppurative  condi- 
tion may  develop. 

Should  the  inflammation  advance  to  a  suppurative  stage  or  be  of  this 
nature  from  the  onset,  the  course  varies,  as  pointed  out  in  discussing 
symptoms.  Periappendicitis  may  be  produced  and  abscess  result,  and 
a  mass  may  then  often  be  outlined  after  2  or  3  days,  the  general  and  other 
local  signs  meanwhile  persisting.  After  this  period  the  sj'taptoms  may 
continue  with  unabated  force  while  the  abscess  grows  larger;  or  they  rnay 
abate  after  4  or  5  days,  except  the  local  evidence  of  increasing  induration. 
The  duration  of  the  attack  in  suppurative  appendicitis  has  no  well- 
defined  limit.  In  some  cases  the  course  is  rapid  from  the  beginning  and 
perforation  maj^  occur  in  2  or  3  days,  or  suppuration  be  found  if  the  case 
is  operated  upon.  In  others  the  abscess  may  growslowly  in  size  forseveral 
weeks.  The  ultimate  termination  in  unoperated  cases  is  very  diverse. 
The  pus,  if  in  small  amount,  may  be  eventually  absorbed,  or  it  may 
extend  itself  in  different  directions  and  discharge  spontaneously  into  the 
colon,  the  rectum,  the  bladder,  through  the  abdominal  wall,  or  by  perfo- 
ration into  the  peritoneal  cavity.  Perforation  with  general  peritonitis 
occurs  most  frequently  in  cases  of  gangrenous  appendicitis.     This  may 


APPENDICITIS    ■  807 

happen  even  in  the  first  2  or  3  days  of  the  attack,  ^vith  few  unfavorable 
symptoms  preceding  the  occurrence.  The  great  majority  of  fatal  cases 
of  appendicitis  depend  upon  perforation  with  general  peritonitis.  The 
prognosis  in  this  condition  is  very  grave,  although  cases  of  recovery 
under  prompt  operative  treatment  are  not  on  the  whole  uncommon 
especially  in  infancy  and  childhood.  The  duration  after  perforation  has 
occurred  varies  from  24  hours  to  a  week  or  sometimes  more,  the  longer 
period  being  the  result  of  protective  adhesions  forming  after  a  sudden 
perforation. 

The  general  prognosis  of  appendicitis  under  medical  treatment  without 
operative  interference  is  not  unfavorable,  owing  to  the  large  proportion  of 
cases  of  catarrhal  appendicitis.  In  fact,  the  large  majority  of  unoperated 
cases  in  private  practice  recover.  The  prognosis  of  the  individual  case, 
however,  is  always  uncertain,  owing  to  the  absolute  impossibilitj'^  of  pre- 
dicating the  likehhood  of  peritonitis  in  any  given  instance.  Those  cases 
which  perhaps  appear  the  mildest  or  to  be  on  the  road  to  recovery  not 
infrequently  become  suddenly  and  dangerously  worse.  The  prognosis 
in  the  first  2  3''ears  of  life  appears  to  be  unfavorable.  This  is  probably 
dependent,  in  reahty,  upon  the  difficulty  in  recognizing  the  disease  at 
this  age,  the  mildest  cases  never  being  discovered,  and  the  fatal  ones 
receiving  a  post-mortem  diagnosis  only.  Certainly  the  majority  of 
patients  at  this  age  in  whom  the  diagnosis  is  made  during  life  do  not 
recover.  Recovery  from  an  attack  of  appendicitis  leaves  the  subject 
predisposed  to  later  attacks,  or  chronic  inflammation  of  varying  degree 
may  remain,  or  adhesions  persist  which  give  rise  to  symptoms. 

Under  early  operative  treatment  the  general  mortality  is  very  low. 
In  the  500  cases  in  children  reported  by  H.  C.  Deaver^  there  were  but 
23  deaths;  i.e.  4.6  per  cent.,  and  the  majority  of  these  were  due  to 
general  peritonitis.  Riedel-  found  a  higher  mortality  than  this:  16.4 
per  cent,  in  310  operated  cases  in  children;  but  he  thinks  this  high  mor- 
taUty  due  to  neglect  on  the  part  of  the  parents,  as  a  result  of  which  opera- 
tion was  often  done  too  late.  One  of  the  dangers  after  operation  is  the 
development  of  intestinal  o))struction  from  paralysis  of  peristalsis;  and 
the  formation  of  secondary  abscesses  is  another.  Even  cases  with  a 
primary  walled-off  abscess  of  considerable  size  generally  recover  when 
operated  upon.  It  is.  only  where  general  peritonitis  has  developed  that 
the  mortality  of  operation  is  high. 

Complications. — ^Alxscess  in  various  parts  of  the  abdominal  and 
pelvic  cavities  has  already  been  referred  to.  Pneumonia,  hepatic  abscess, 
phlebitis,  and  other  evidences  of  sepsis  may  follow  a  septic  peritonitis. 
Empyema  may  be  the  result  of  the  penetration  of  a  subphrenic  ai)scess 
into  the  pleural  cavity  or  of  the  sepsis  following  j)erfoi'ation.  Pleurisy, 
not  of  a  purulent  nature,  is  a  not  infnujucnt  coniplication.  .Appendicitis 
may  l)e  complicated  by  hernia,  and  the  inflamed  appendix  may  be  found 
in  the  hernial  sac.  (See  Hernia,  j).  700.)  So,  too,  ai)pendicitis  may  be 
follow(Ml  by  intussusception,  as  in  a  ciiild  of  5  months  rc'portcd  by  Uardin.-^ 

Diagnosis.-— The  principal  diagnostic  symptoms  in  typical  cases  are 
sudden  onset;  early  vomiting  and  fever;  and  abdominal  pain,  tenderness, 
increased  resistance,  and  later  induration  or  tumor  especially  in  the  right 
iliac  region.     But  the  variations  as  already  descril)ed  are  so  great  that 

'  Loc.  cit. 

2  Miinch.  ined.  Wochcnschr..  1907,  LIV,  23(15. 

»  Virginia  Med.  Semi-inontlily,  1901,  VI,  398. 


808  THE  DISEASES  OF  CHILDREN 

diagnosis  is  often  difficult,  and  the  early  distinguishing  of  the  different 
forms  of  appendicitis  from  each  other  is  practically  impossible.  The 
diagnosis  in  infancy  is  usually  only  conjectural,  owing  to  the  impossibility 
of  obtaining  answers  to  questions  or  of  determining  with  any  exactness 
the  existence  or  position  of  pain. 

A  number  of  other  morbid  conditions  are  to  be  taken  into  considera- 
tion in  reaching  a  conclusion.  Appendicular  colic,  in  which  the  con- 
traction of  the  appendix  in  expelling  retained  secretion  or  fecal  masses 
causes  pain,  is  unproductive  of  fever,  tenderness,  leucocytosis,  or  the 
constitutional  disturbance  which  appendicitis  usually  presents.  When 
there  is  fever  the  diagnosis  is  at  times  uncertain.  Intestinal  colic  may 
cause  peculiar  difficulty  if  there  happens  to  be  a  large  fecal  accumulation 
in  the  colon,  particularly  the  cecum.  Acute  febrile  indigestion  closely 
simulates  many  cases  of  appendicitis  at  the  onset  and  diagnosis  at  first 
may  be  impossible.  Generally,  however,  the  pain  is  less  intense  and  the 
constitutional  symptoms  less  marked,  except  that  the  fever  is  often 
high.  Intussusception  might  simulate  appendicitis  in  the  presence  of 
constipation  and  of  tumor.  General  symptoms,  however,  are  absent 
early  in  the  disease  and  appear  only  later;  while  appendicitis  is  ushered 
in  by  fever,  vomiting,  and  other  acute  manifestations.  Ileocolitis  may 
resemble  appendicitis  and  at  first  cause  confusion  through  the  early 
presence  of  vomiting  and  of  abdominal  pain;  but  the  symptoms  in  gen- 
eral are  so  different  that  the  diagnosis  soon  becomes  clear.  I  have  seen 
acute  tuberculous  inflammation  of  the  lymph-glands  near  the  cecum  resemble 
appendicitis  so  closely  that  operation  was  performed  with  the  mistaken 
diagnosis.  Many  similar  cases  are  on  record.  The  subject  has  been  re- 
viewed by  Gage^  and  others.  Typhoid  fever  may,  at  the  onset,  suggest 
appendicitis  to  a  certain  extent,  through  the  vomiting  and  the  tenderness 
in  the  right  iliac  region;  but  the  course  of  the  temperature,  the  absence 
of  leucocytosis,  and  later  the  presence  of  the  Widal  reaction  serve  to 
differentiate.  The  diagnosis  is,  however,  sometimes  difficult  and  I  have 
seen  children  with  typhoid  fever  operated  upon  under  the  mistaken  behef 
that  appendicitis  was  present.  The  occasional  reference  by  the  patient  of 
appendicular  pain  to  the  region  of  the  right  hip  may  cause  the  diagnosis 
of  hip-joint  disease  to  be  made.  Careful  examination  of  the  hip  will 
prevent  the  mistake.  Ovarian  disease  has  likewise  occasioned  errors 
in  several  instances;  and  urinary  symptoms  may  usher  in  appendicitis 
and  cause  confusion.  The  employment  of  a  catheter,  if  there  is  retention, 
and  the  examination  of  urine  obtained  will  aid  in  coming  to  a  decision. 
Unusual  location  of  the  appendicular  abscess  leads  to  mistakes  later  in 
the  disease,  and  the  possibility  of  a  psoas  abscess  from  spinal  caries  simu- 
lating a  perityphhtic  abscess  must  not  be  forgotten.  Inflammation  of 
Meckel's  diverticulum  has  repeatedly  been  supposed  to  be  appendicitis, 
and  operation  has  been  done  for  this  condition;  and  there  exists  no  certain 
differential  diagnostic  feature.  (See  Diseases  of  Meckel's  Diverticulum, 
p.  809.)  The  error  of  believing  a  pleurisy  or  pneumonia  to  be  an  appendi- 
citis is  probably  much  more  frequent  than  ordinarily  supposed,  and  has 
repeatedly  led  to  operation  upon  perfectly  normal  appendices.  Writing 
in  1903^  1  reviewed  the  subject  with  the  report  of  a  number  of  cases  of 
what  may  be  called  "appendicular  pneumonia,"  (see  Vol.  II,  p.  80) ,  and  since 
then  I  have  observed  a  number  of  additional  instances  and  know  of  some 
where  surgeons  of  experience  have  operated.     It  is  of  common  occurrence, 

1  Boston  Med.  and  Surg.  Jour.,  1915,  CLXXIII,  301. 

2  Jour.  Arner.  Med.  Assoc,  1903,  Aug.  29. 


DISEASES  CONNECTED  WITH  MECKEL'S  DIVERTICULUM      809 

especially  in  children,  for  the  pain  produced  in  the  pleura  to  be  referred 
through  the  intercostal  and  abdominal  nerves  to  the  region  of  the  appen- 
dix. A  mistake  in  diagnosis  is  to  be  avoided  chiefly  by  careful  examina- 
tion of  the  lungs  in  every  case  of  suspected  appendicitis;  by  noting  the 
increased  rapidity  of  respiration  in  pneumonia;  and  by  the  fact  that  the 
abdominal  resistance  is  generally  relaxed  during  inspiration  in  this  disease, 
but  is  maintained  in  appendicitis.  Lastly  it  must  not  be  forgotten  that, 
in  the  case  of  older  children  especially,  pain  in  the  right  iliac  region  may 
be  psychic  in  nature,  the  result  of  the  mental  impression  made  by  what 
the  patients  have  heard  regarding  the  disease.  The  absence  of  fever  and 
of  tumor  is  suggestive,  although  a  simulated  tenderness  of  course  is 
present.     The  diagnosis  is  often  difficult. 

Treatment. — Non-surgical  treatment  is  that  indicated  for  catarrhal 
appendicitis,  and  the  majority  of  such  cases  will  recover.  In  view 
however,  of  the  impossibility,  already  referred  to,  of  determining  whether 
a  case  is  catarrhal,  suppurative,  or  gangrenous,  the  only  safe  treatment  is 
operative  interference.  This  is  especially  true  of  infancj^  and  childhood, 
at  which  time  the  danger  of  peritonitis  is  greater.  If  the  patient  is  seen 
early  operation  should  be  done  at  once.  If  an  exudate  has  already  taken 
place,  the  time  for  operation  is  to  be  determined  for  each  individual  case, 
it  being  sometimes  better  to  delay  until  the  abscess  has  become  more 
distinctly  localized.  Under  this  condition,  if  symptoms  subside  and  pus 
does  not  form,  operation  may  be  unnecessary  and  resolution  allowed  to 
go  on  without  interference.  But  here  again  we  are  confronted  with  the 
possibility  of  sudden  perforation  in  cases  where  it  was  supposed  that  no 
suppuration  existed. 

When  for  any  reason  early  operation  cannot  be  done,  or  when  the 
diagnosis  is  uncertain,  and  in  cases  seen  later  in  which  operation  is  de- 
ferred by  surgical  advice,  medical  treatment  must  be  instituted.  The 
patient  must  be  kept  at  rest  in  bed,  given  a  very  light  diet,  and  an  ice- 
bag  be  applied  over  the  seat  of  inflammation.  Vomiting  may  need  to 
be  controlled  by  the  temporary  abstaining  from  food  or  the  taking  of  it 
in  very  small  amount,  and  the  administration  of  appropriate  remedies, 
such  as  the  swallowing  of  ice,  iced  champagne,  or  the  giving  of  lime  water 
or  bismuth.  No  saline  or  other  purgative  should  be  administered,  and 
unirritating  enemata  should  be  employed  if  it  is  necessary  to  relieve  con- 
stipation. If  acute  symptoms  have  subsided  opium  is  better  avoided 
if  possible,  as  it  obscures  symptoms  and  increases  constipation  and  tym- 
panites. Cases  where  pain  is  very  severe  sometimes,  however,  make  opium 
a  necessity,  and  where  operation  cannot  be  done  and  the  possibility  of 
increasing  tympanites  by  the  drug  is  kept  in  mind,  there  seems  no  remedy 
more  certainly  indicated  than  opium  for  the  relief  of  this  symptom. 

Where  there  have  been  several  attacks  of  recurrent  appendicitis,  even 
though  slight,  it  is  best  to  remove  the  appendix,  as  there  is  no  predicat- 
ing under  what  inopportune  circumstances  a  severe  or  even  fatal  attack 
might  occur.  The  operation  is  then  conveniently  performed  in  the 
interval  between  attacks. 

DISEASES  CONNECTED  WITH  MECKEL'S  DIVERTICULUM 

The  omplialo-mosentoric  duct  passing  in  fetal  life  from  the  ileum  to 
tiie  umbilical  vesicle  remains  after  i)irth  in  from  1  to  2  per  cent,  of  all 
persons  as  what  is  known  as  "Meckel's  diverticulum."  This  may  exist 
only  as  a  short  patulous  protrusion  from  the  ileum,  oftcncst  from  its  con- 
vex border  and  found  at  from  1  to  3  feet  (31  to  91  cm.)  above  the  cecum; 


810  THE  DISEASES  OF  CHILDREN 

as  a  tube  wholly  or  partially  open;  or  as  a  cord  merely,  extending  entirely 
or  a  portion  of  the  wa}^  to  the  umbilicus,  and  in  the  latter  event  either 
free  at  its  distal  extremity,  or  attached  to  some  other  region,  oftenest 
the  mesentery.  The  organ  is  found  much  most  frequently  in  males. 
Lesions  are  more  likely  to  develop  if  the  distal  extremity  is  attached. 
As  a  rule  the  diverticulum  gives  rise  to  no  symptoms  whatever,  yet  it 
is  oftener  the  cause  of  pathological  conditions  than  is  usually  supposed. 
Series  of  cases  of  such  disturbances  have  been  reported,  and  I  have  re- 
viewed the  subject  in  a  previous  publication.^  Only  a  brief  resume  can 
be  given  here. 

1.  Strangulation  of  the  Intestine  by  the  Diverticuliun. — This  is  the  most 
frequent  lesion  found.  Of  Wellington's^  326  cases  of  disease  of  the  di- 
verticulum, 144  were  instances  of  constriction  of  the  intestine  by  this 
organ  or  its  remains.  In  991  cases  of  intestinal  strangulation  from 
different  causes  collected  by  Halsted^  6  per  cent,  were  dependent  upon 
the  diverticulum.  The  majority  of  these  cases  occurred  after  the  period 
of  childhood.  The  symptoms  of  strangulation  by  the  diverticulum  are 
those  of  intestinal  obstruction  in  general,  with  the  exception  of  intus- 
susception, which  has  characteristic  symptoms  of  its  own. 

2.  Patulous  Meckel's  Diverticuliun  Opening  at  the  Umbilicus. — This  is 
an  uncommon  condition  nearly  always  seen  only  in  males,  of  which 
Strasser^  could  collect  but  63  instances.  I  have  met  with  it  in  but  1 
case.  The  mucous  membrane  of  the  diverticulum  protrudes  at  the  um- 
bilicus, producing  a  small  tumor  covered  by  mucous  membrane,  and  with  a 
central  fistulous  opening.  Should  the  entire  wall  of  the  intestine  project 
as  well  as  the  mucous  membrane  of  the  duct,  the  tumor  is  larger  and  with 
two  lateral  openings.  Strangulation  of  the  projecting  portion  may  occur. 
When  the  diverticulum  is  open  throughout  its  extent,  feces  and  even 
intestinal  worms  may  be  discharged  at  the  umbilicus;  but  if  closed  at  its 
proximal  extremity,  only  mucus  is  passed  at  the  opening.  The  cases 
of  fecal  fistula  usually  terminate  fatally.  (See  also  Diseases  of  the 
Umbilicus,  p.  295.) 

3.  Invagination  of  the  Diverticuliun. — Of  Wellington's  cases  59  exhibited 
this  lesion.  Not  only  may  the  diverticulum  be  itself  invaginated,  but  it 
may  be  followed  by  an  intussusception  of  the  ileum  also.  The  accident 
takes  place  usually  not  before  later  childhood,  this  distinguishing  it  from 
ordinary  intussusception,  which  is  so  much  more  common  at  a  decidedly 
earlier  age.  The  obstruction  of  the  intestine  is  usually  not  complete, 
and  the  amount  of  blood  discharged  is  small. 

4.  Volvulus  of  Meckel's  diverticulum  is  a  rare  condition,  either  excep- 
tionally of  the  diverticulum  alone,  or  oftener  of  the  ileum  also  second- 
arily to  this,  or  dependent  upon  the  presence  of  the  diverticulum  but 
without  twisting  of  it. 

5.  Hernia  of  the  diverticulum  is  occasionally  seen.  Gray^  collected  42 
undoubted  cases. 

6.  Diverticulitis. — The  disease  of  the  diverticulum  bearing  this  title 
is  of  especial  interest  because  it  may  simulate  appendicitis  so  closely 
that  the  diagnosis  is  impossible.  It  is  an  infrequent  condition,  the 
largest  series   of   collected   cases  reported   being   that   of   Forgue  and 

1  Jour.  Amer.  Med.  Assoc,  1914,  LXII,  1624. 

2  Surg.,  Gynec.  and  Obstet.,  191.3,  XVI,  74. 

3  Annals  of  Surgery,  1902,  XXXV,  471. 
'  Med.  Rec,  1903,  LXIV,  933. 

6  Brit.  Med.  Jour.,  1907,  II,  823;  1908,  II,  909. 


PROLAPSE  OF  THE  RECTUM  AND  ANUS  .  811 

Riche^  with  59  instances.  About  V3  of  the  instances  occur  in  children 
(Cahier).^  The  diseasemay  besecondary  to  some  other  lesion  of  thediver- 
ticulum,  or  arise  as  a  primary  affection.  The  method  of  production  and 
the  pathological  anatomy  in  this  primary  diverticulitis  are  entirely  similar 
to  those  seen  in  appendicitis,  and  the  different  varieties  are  the  same.  The 
course  may  be  acute  or  chronic.  The  symptoms  strongly  suggest  appen- 
dicitis, and  consist  of  abdominal  pain,  nausea,  vomiting,  often  constipa- 
tion, fever,  leucocj^tosis,  and  the  development  of  abdominal  tenderness  and 
resistance,  with  dullness  on  percussion.  In  a  few  cases  discharge  of  blood 
from  the  bowel  has  occurred.  In  a  case  under  my  care  severe  anemia 
was  produced  in  this  way.  Perforation  and  septic  peritonitis  may  take 
place;  or  in  other  instances  intestinal  obstruction  may  result  from  com- 
pression by  the  inflammatorj^  mass,  or  in  other  ways.  In  secondary 
diverticulitis  intestinal  obstruction  may  first  occur,  and  later  the  evi- 
dences of  inflammation  of  the  diverticulum  be  added.  The  diagnosis 
of  diverticulitis  from  appendicitis  rests  chiefly  on  the  localization  of  pain 
to  the  right  of  the  umbilicus  and  somewhat  higher  than  McBurney's 
point,  or  in  some  more  distant  region.  Further  suggestive  of  diver- 
ticulitis are  the  absence  or  slight  degree  of  tympanites,  and  in  some  cases 
the  presence  of  blood  in  the  stools.  Nearly  all  cases,  however,  have  been 
diagnosed  as  appendicitis. 

The  only  treatment  of  diseases  of  Meckel's  diverticulum  is  operative 
interference.  Indeed,  should  the  organ  in  a  healthy  state  be  discovered 
at  any  abdominal  operation  for  other  conditions,  it  is  a  wise  course  to 
remove  it,  since  its  presence  is  a  constant  menace  to  life. 


CHAPTER  VII 
DISEASES  OF  THE  INTESTINE  (CONTINUED) 

PROLAPSE  OF  THE  RECTUM  AND  ANUS 

Etiology. — This  is  a  rather  common  affection  of  childhood,  especially 
of  the  first  3  years  of  life,  although  not  often  seen  in  the  first  6  months. 
It  occurs  oftenest  where  there  has  been  repeated  decided  straining  at 
stool,  and  hence  it  is  a  frequent  complication  of  ileocolitis  or  of  diarrhea 
from  other  cause.  Chronic  constipation  may  produce  it  for  the  same 
reason,  as  may  stone  in  the  bladder,  phimosis  or  other  urethral  obstruc- 
tion, thread-worms,  rectal  polj^pus,  or  other  cause  of  tenesmus.  It  is 
also  common  in  debilitated  subjects  in  whom  the  sphincter  ani  has  lost 
its  tone,  even  without  there  having  been  excessive  straining.  Under 
these  conditions  it  may  be  a  complication  of  pertussis.  The  anatomical 
relationships  of  tlie  rectum  in  early  life  favor  the  occurrence  of  prolapse, 
among  them  being  its  more  vertical  position  and  the  less  firm  attachment 
to  the  neigh boiing  parts.  Sitting  low  when  at  stool  and  upon  a  vessel 
with  a  wide  opening,  as  the  ordinary  chamber-pot,  is  another  predis- 
posing factor. 

Symptoms.- — The  condition  is  practically  a?i  invagination  develop- 
ing at  the  anus.  The  prolapse  may  be  only  i)artial  and  limited  to  the 
opening  of  the  bowel  (proldp.sc  of  the  anus),  not  more  than  a  slight  ring- 

»  Le  Divert iculc  d.-  Meckel,   1<.M)7. 

^  Rev.  de  cliir.,  1<M)6,  XXXiV,  33S;  550. 


812  THE  DISEASES  OF  CHILDREN 

shaped  eversion  of  the  mucous  membrane  showing  itself.  In  the  more 
typical,  severer  complete  prolapse  {prolapse  of  the  rectum.)  there  is  a  con- 
siderable portion  of  the  rectum  extruded  including  all  the  coats,  and 
forming  a  sausage-shaped  or  more  globular,  soft,  dark-red  mass,  some- 
what furrowed,  more  or  less  coated  with  mucus,  and  often  with  slightly 
bleeding  points  especially  if  handled  (Fig.  263).  At  the  part  furthest  re- 
moved from  the  body  is  a  small  depression,  indicating  the  much  nar- 
rowed lumen  of  the  gut.  The  presence  of  the  tumor,  if  the  case  is  an 
acute  one,  causes  constant  efforts  at  straining.  As  a  rule  the  prolapse 
occurs  only  at  stool,  or  when  there  is  a  straining  effort  from  other  causes; 
but  sometimes,  in  severe  and  obstinate  cases,  even  walking  about  the 
room  may  be  sufficient  to  cause  an  extensive  prolapse  to  occur,  which 
may  remain  down  with  few  subjective  symptoms. 


Fig.  26;^. — Prolapse  of  the  Anus. 
From  a  patient  in  the  Children's  Hospital  of  Philadelphia. 

Course  and  Prognosis. — In  mild  prolapse,  as  of  the  mucous  mem- 
brane only,  the  condition  is  self-reducing  after  defecation,  and  examina- 
tion shows  only  blood  and  mucus  in  small  amount  with  the  stool  as 
an  evidence  of  the  disease.  In  more  severe  cases  the  compression  of 
the  extruded  gut  by  the  anal  sphincter  causes  swelling  and  the  prolapse 
persists  unless  treatment  is  employed  to  accomplish  reduction.  The 
prognosis  is  good,  yet  the  duration  may  be  long-continued  before  the 
tendency  to  recurrence  is  overcome.  Rarely  in  some  severe  cases  necro- 
sis of  the  mucous  membrane  may  result  from  incarceration. 

Diagnosis. — This  is  usually  easy.  The  only  condition  at  all  re- 
sembling it  is  an  ileocecal  intussusception  which  has  reached  the  anus 
and  is  beginning  to  protrude  from  it.  This  may  be  recognized  by  the 
fact  that  the  finger  can  be  passed  well  upward  between  the  sphincter 
and  the  protruding  bowel. 

Treatment. — The  first  indication  is  to  replace  the  extruded  bowel, 
should  prolapse  be  present  at  the  time.  As  a  rule  this  is  readily  accom- 
plished. The  bowel  and  the  hands  of  the  physician  are  well  oiled  and  a 
steady,  gentle  pressure  made  until  normal  relations  are  obtained.  Should 
the  oiled  intestine  slip  too  readily  from  the  grasp  of  the  fingers,  a  soft 
linen  or  similar  cloth  may  be  interposed.  The  central  portion  of  the 
prolapse,  showing  the  position  of  the  opening,  should  be  reduced  first.  In- 
verting the  child  may  be  useful  in  some  cases.  Sometimes  the  applica- 
tion of  ice-cold  compresses  diminishes  the  congestion  and  swelling  in 


PROCTITIS 


813 


more  obstinate  cases  and  renders  the  reduction  easier.  It  may  be  neces- 
sary to  dilate  the  sphincter  with  the  finger  in  cases  where  the  prolapse 
has  lasted  some  time. 

The  most  important  and  most  difficult  part  of  treatment  is  to  prevent 
recurrence.  To  accomplish  this  some  support  must  be  given,  especially 
at  the  time  of  defecation,  in  such  a  vvay  that  the  anal  opening  is  narrowed. 
The  child  should  lie  upon  its  back  or  side,  the  feces  being  passed  into  a 
wad  of  oakum  or  other  soft  material,  the  nates  being  meanwhile  pressed 
together  by  the  attendant.  Older  children  may  sit  upon  a  specially  pre- 
pared seat  which  may  be  put  in  position  over  the  ordinary  infant's  chair 
or  the  toilet  (Fig.  264).  The  circular  aperture  is  3  or  4  inches  (8  or  10 
cm.)  in  diameter  and  the  child  is  placed  over  this  in  such  a  way  that  the 
anus  is  immediately  over  the  opening.  The  slot  extending  forward  allows 
the  passage  of  urine.  The  seat  should  be 
sufficiently  high  from  the  floor  to  prevent  the 
thighs  from  flexing  unduly  on  the  abdomen, 
and  the  child  should  be  prevented  from  lean- 
ing forward.  The  apparatus  supports  the 
tissues  about  the  anus  and  prevents  the 
spreading  effect  which  attends  straining  efforts. 

In  cases  where  prolapse  occurs  very  fre- 
quently, even  without  effort  at  stool,  efficient 
support  may  often  be  rendered  by  drawing 
the  buttocks  firmly  together  with  a  broad 
strip  of  adhesive  plaster  crossing  them  trans- 
versely. This  I  have  generally  found  effective. 
Constipation  is  to  be  prevented  by  gentle 
laxatives;    diarrhea   checked   by  appropriate 

remedies.  Frequent  bathing  of  the  anal  region  with  cold  water  helps 
to  contract  the  anus  and  give  tone  to  the  parts.  Sometimes  the  inser- 
tion of  tannic-acid  suppositories  is  of  service  in  a  similar  manner.  Tonic 
measures  of  various  sorts  are  also  required,  such  as  effective  hygiene, 
abundant  suitable  nourishment,  and  the  administration  of  strychnine, 
quinine,  or  iron.  The  rectal  injection  of  a  solution  of  adrenalin  chloride 
has  been  advocated,  and  good  results  claimed  (]\Iiserocchi).^  Should 
the  measures  recommended  be  ineffectual,  operative  procedures  are  re- 
quired. These  consist  generally  of  cauterization  of  some  sort,  but  so 
vigorous  a  treatment  is  seldom  necessary.  The  injection  of  paraffin 
into  the  pararectal  tissue  has  also  been  employed  with  success. 


Fig.    264. — Toilet-seat     for 
Prolapse  of  the  Rectum. 

To  be  used  over  the  seat  of  the 
ordinary  nursery-chair. 


PROCTITIS 

Inflammation  of  tlu;  I'ectum  may  attend  ileocolitis,  or,  much  less 
often,  may  occur  independently  of  this.  When  the  two  arc  combined 
the  symptoms  are  in  no  way  characteristic,  and  need  not  be  considered 
further  here.  Inflammation  limited  to  the  rectum  will  alone  receive 
our  attention. 

Etiology. — Trauma  is  among  the  causes;  such  as  is  produccMl  by  too 
frequent  administration  of  enemata,  csjiecially  of  an  irritating  naturi>. 
The  use  of  the  soap-stick  or  of  glyerine-suppositorios  may  occasionally 
act  in  the  same  way.  Not  uncommonly  a  gonorrheal  inflammation  of 
the  rectum  is  produced  by  the  extension  from  vulvovaginitis,  or  by  the 
employnnnit  of  an  infected  thermometer;  or    rarely  in  older  children 


La  I'(Mli:itri;i.   I'M)-),  .\11I,  380. 


814  THE  DISEASES  OF  CHILDREN 

by  rectal  copulation.  The  presence  of  the  oxyuris  may  somethnes  pro- 
duce inflammation,  and  the  disease  may  follow  the  infectious  fevers. 

Symptoms. — -There  is  usually  not  the  constitutional  involvement 
seen  in  ileocolitis,  the  symptoms  being  mainly  local,  and  consisting  of 
rectal  pain,  tenesmus,  and  the  discharge  of  bloody  mucus.  The  latter 
is  often  not  mingled  with  the  stool,  but  perhaps  passed  before  the  feces 
appear.  Irritation  of  the  bladder  not  infrequently  accompanies  proc- 
titis and  prolapse  of  the  rectum  is  common.  When  the  inflammation  is 
severe,  ulcerative  changes  may  take  place  in  the  rectum  and  the  discharge 
contain  pus,  and  not  uncommonly  blood  in  small  or  even  large  amount. 
In  some  instances  of  a  more  continued  nature,  as  in  those  due  to  tuber- 
culosis, ulceration  may  be  present  with  but  little  pain,  and  there  may  be 
no  tenesmus  unless  the  lesion  is  in  the  lower  part  of  the  rectum.  Oc- 
casionally a  pseudomembranous  inflammation  of  the  rectum  is  found, 
depending  upon  the  action  of  the  diphtheria-bacillus  or  of  the  pneumococ- 
cus  or  streptococcus.  The  symptoms  of  this  are  those  already  described, 
with  the  addition  of  the  discovery  of  the  pseudomembrane  by  inspec- 
tion of  the  bowel,  or  of  the  presence  of  it  in  the  passages.  The  course 
of  proctitis  is  usually  acute,  and  the  prognosis  favorable,  the  symptoms 
subsiding  in  a  few  days.  Sometimes,  however,  the  condition  passes 
into  a  chronic  form. 

Treatment. — The  first  indication  is  the  removal  of  the  cause.  In 
the  acute  condition  the  patient  should  be  kept  in  bed  and  given  injec- 
tions of  boric  acid,  starch  water  or  normal  saline  solution  several  times 
daily.  The  diet  should  be  entirely  unirritating  and  the  tenesmus  re- 
lieved by  opiates  if  necessary.  Later  a  weak  solution  of  tannic  acid 
(0.5  per  cent.),  or  of  silver  nitrate  (0.1  per  cent.),  or  stronger  solutions 
of  argyrol  or  protargol  are  often  of  benefit.  Suppositories  of  tannic 
acid  may  be  serviceable. 

FISSURE  OF  THE  ANUS 

Etiology. — Although  not  encountered  so  often  as  in  adults,  this  is 
by  no  means  uncommon  in  early  life,  being  seen  probably  oftener  in 
infancy  than  in  childhood.  Congenital  syphilitic  ulceration  is  an  occa- 
sional cause,  and  injury  done  by  the  use  of  a  syringe  may  occasion  it. 
The  irritation  produced  by  the  oxyuris  or  by  eczema  may  result  in  fissure 
through  the  scratching  which  is  indulged  in.  When  occurring  in  older 
children,  the  most  frequent  cause  is  constipation  with  the  passage  of 
large  scybalous  masses.  Once  formed  the  fissure  is  likely  to  be  kept 
open  by  the  irritation  of  the  feces  passing  over  it,  and  by  the  alternate 
expansion  and  contraction  of  the  anus  which  occurs  during  defecation. 

Pathological  Anatomy. — The  lesion  consists  in  a  linear  break  in 
the  mucous  membrane  discovered  by  careful  examination  at,  or  slightly 
above,  the  margin  of  the  anus,  and  oftenest  on  the  posterior  wall.  If 
of  long  duration  it  extends  sometimes  well  above  the  anus,  its  edges  are 
indurated,  and  the  surface  grey  or  yellow  and  secreting  a  small  amount 
of  pus,  and  bleeding  slightly  when  touched.  lit  the  most  severe  cases 
there  may  be  a  number  of  such  fissures  present.  To  I'cveal  the  lesion 
the  child  should  be  laid  upon  the  side  or  back  with  the  legs  flexed  as 
closely  upon  the  abdomen  as  possible,  and  the  buttocks  should  then  be 
pulled  apart  firmly,  thus  opening  the  sphincter  and  allowing  the  rectal 
mucous  membrane  to  prolapse  slightly.  A  digital  examination  of  the 
rectum  for  polypus  should  also  be  made,  as  this  condition  sometimes 
accompanies  fissure. 


INCONTINENCE  OF  FECES  815 

Symptoms. — The  symptoms  consist  in  pain  on  defecation  and 
following  it,  and  the  discharge  of  a  small  amount  of  blood  which  may 
streak  the  stool.  The  pain  is  often  verj'  severe,  and  the  patient  abstains 
from  defecation  as  long  as  possible.  Sometimes  incontinence  or  reten- 
tion of  urine  is  observed  as  a  reflex  disturbance,  or  pain  may  radiate  to 
the  legs,  and  may  produce  lameness  and  other  symptoms  strongly  sug- 
gesting hip-joint  disease.  This  has  been  emphasized  especially  by 
Svehla.  ^     Various  nervous  symptoms  occasionally  develop. 

Treatment. — That  of  the  recent  milder  cases  consists  in  keeping  the 
stools  soft,  the  rectum  clean  after  defecation  by  the  use  of  small  enemata 
or  of  petrolatum  on  cotton,  and  the  careful  application  of  a  5  per  cent, 
solution  of  nitrate  of  silver,  or  of  the  solid  stick,  followed  by  a  soothing 
ointment.  Sometimes  the  employment  of  a  2  per  cent,  cocaine-oint- 
ment, cautiously  in  young  children,  to  the  region  of  the  fissure  before 
defecation  occurs  anesthetizes  the  parts  and  prevents  the  pain.  The 
passage  of  a  stool  may  then  be  produced  by  a  small  unirritating  injection, 
as  of  oil  or  of  normal  salt  solution.  In  obstinate  cases  unrelieved  by  the 
procedures  mentioned,  dilatation  of  the  external  sphincter  and  cauteriza- 
tion of  the  fissure  under  general  anesthesia  may  be  required. 

ISCHIORECTAL  ABSCESS 

Ischiorectal  abscess  is  a  by  no  means  uncommon  condition  in  early 
life,  especially  in  infancy.  It  consists  of  an  accumulation  of  pus  in  the 
cellular  tissue  about  the  rectum,  and  differs  in  no  way  from  the  condition 
as  seen  in  adults.  It  may  result  from  trauma,  deep  fissures  of  the  anus, 
phlebitis  of  the  hemorrhoidal  veins,  or  infection  of  the  lymph-channels. 
There  develops  fever  without  discoverable  cause,  since  the  abscess  is  often 
entirely  overlooked  for  some  time,  owing  to  the  impossibility  of  complaint 
by  the  youthful  patient.  Digital  examination  shows  a  bulging  of  the 
wall  of  the  rectum,  and  inspection  often  an  indurated  or  fluctuating  red 
area  in  the  anal  region.  Treatment  consists  in  prompt,  free  incision. 
As  a  rule,  the  abscess  heals  readily,  and  only  exceptionally  does  an  anal 
fistula  occur.  Fistula  is,  in  fact,  of  very  rare  occurrence  in  early  life. 
According  to  Mitchener'  in  1500  cases  of  this  operated  upon  in  St. 
Thomas's  Hospital  only  .12  were  in  children. 

INCONTINENCE  OF  FECES 

For  this  disease  there  are  various  etiological  factors.  Lack  of  proper 
training  nuiy  cause  its  persistence  for  some  time  after  the  control  of  the 
b()W(!l  should  ordinari!}'  have  l)eeM  attained.  In  these  cases  the  trouble 
is  l)ut  temporary.  In  greatly  debilitated  states  and  in  the  course  of  many 
severe  acute  diseases,  fecal  incontinence,  similar  to  incontinence  of  urine, 
may  be  present  for  a  time  until  convalescence  from  the  primary  dis- 
ease is  under  way.  In  still  other  conditions  incontinence  of  feces  depends 
upon  some  local  condition  of  the  lower  rectum  and  the  sphincter,  such  as 
dysenteric  diarrhea,  or  overdistention  of  the  rectum  from  chronic  con- 
stipation, or  may  ))e  the  i'(>sult  of  an  old  piolapsc^  of  the  rectum,  a  recto- 
vaginal fistula,  or  (ijf.riier  stretching  of  the  spiiincter  for  fissure.  The  most 
serious  cases  are  tiiose  associated  with  diseases  of  the  mind  and  the  nerv- 
ous system.  Thus  well-marked  cases  of  idiocy  may  never  learn  to  (exer- 
cise  control    o\'(M'    the   bowels,   and    thei-e   may    \iv   incontinence   in    the 

'  Jaliil).  f.  KiiuhM-li.,  H)()().  LXIII.  1S7. 
-  Brit.  Jour,  of  Sinn..  191  t  1.").  II,  'MW. 


816  THE  DISEASES  OF  CHILDREN 

paroxysms  of  epilepsy  or  during  severe  chorea.  Various  lesions  of  the 
spinal  cord  may  be  attended  by  fecal  incontinence,  among  them  being 
spina  bifida  and  the  different  forms  of  myelitis.  For  many  of  these  cases 
there  is  no  relief  possible,  while  in  others  recovery  may  take  place  after  a 
time,  the  prognosis  depending  upon  that  of  the  primary  disease. 

Exceptionally  fecal  incontinence  is  a  purely  functional  disturbance 
analogous  to  enuresis.  I  have  reported  I  such  instance  in  a  boy  of  8 
years, ^  and  cases  have  been  published  by  others,  and  the  subject  reviewed 
especially  by  Ostheimer.-  In  some  instances  incontinence  of  this  nature 
has  depended  upon  some  reflex  irritation;  a  vesical  calculus  in  one  of 
Ostheimer's  cases,  and  apparently  upon  hypertrophy  of  the  tonsils  in 
an  instance  reported  by  Silvestri.^  Cases  of  this  purely  functional 
nervous  nature  seem  much  more  common  in  boys.  The  incontinence 
may  occur  at  night-time  only,  or  in  the  waking  hours  as  well;  and  the 
stools  ma}''  be  formed  or  loose  in  character.  The  disease  may  last  from 
birth,  or  may  come  on  only  when  the  patient  is  deteriorated  in  health 
or  is  undergoing  some  special  nervous  strain.  It  maj"  yield  readily, 
or  may  prove  troublesome  to  cure.  General  treatment  is  required,  in- 
cluding that  of  a  tonic  nature,  such  as  cool  bathing,  outdoor  life,  and  the 
administration  of  str3^chnine  or  arsenic.  Sometimes  belladonna  and  the 
bromides  act  favorably,  as  in  enuresis. 

HEMORRHOIDS 

The  occurrence  of  hemorrhoids  is  very  uncommon  in  childhood, 
although  exceptionally  they  may  be  found  very  early  in  life.  I  have  seen 
the  disorder  in  an  infant  of  12  months.  In  rare  instances  it  may  be  con- 
genital (Milward)  ;^  but  the  condition  is  then  not  in  reality  a  pile,  but  a 
small  benign  neoplasm  of  a  fibrous  and  fatty  nature,  and  has  no  real 
resemblance  to  the  ordinary  hemorrhoid.  As  in  adults,  hemorrhoids  may 
be  either  external  or  internal  in  nature,  and  are  oftenest  the  result  of 
chronic  constipation.  They  may  also  be  produced  by  sitting  at  stool 
upon  a  low  wide-mouthed  receptacle,  as  happens  in  the  case  of  prolapse 
of  the  anus.  Tonic  remedies  are  usually  indicated,  since  the  children 
are  frequently  debilitated  subjects.  Other  treatment  is  similar  to  that 
effectual  in  adult  life;  chiefly  the  employment  of  cold  local  bathing  and  a 
mild  astringent  ointment. 

PRURITUS  ANI 

This  annoying  affection  is  not  unusual  in  children,  although  less  so 
than  in  adult  life.  It  is  a  symptom  of  many  diverse  conditions.  In 
children  the  most  frequent  cause  is  the  presence  of  the  oxyuris;  but 
eczema,  hemorrhoids,  constipation,  indigestion  from  improper  foods,  and 
slight  prolapse  may  produce  it  likewise.  The  treatment  is  that  of  the 
cause,  and  this  must  be  sought  for  diligently.  As  palliative  measures, 
in  cases  where  no  certain  cause  is  discoverable,  application  of  cold  water 
or  of  hot  water  is  often  serviceable,  as  are  ointments  of  cocaine,  tar, 
carbolic  acid,  menthol,  and  the  painting  with  compound  tincture  of 
benzoin  or  with  tincture  of  iodine. 

1  Arch,  of  Ped.,  1899,  June. 

2  Univ.  of  Pa.  Med.  Bull.,  1905,  XVII,  405;  Jour.  Amer.  Med.  Assoc,  1907,  XLIX, 
1115. 

3  Gaz.  degli.  ospedali,  1904,  XXV,  46. 
*  Lancet,  1907,  I,  1489. 


FOREIGX  BODIES  IN  THE  IXTESTIXAL  CAXAL  817 

FOREIGN  BODIES  IN  THE  INTESTINAL  CANAL 

The  constant  tendency  of  infants  to  put  small  objects  into  their  mouths 
makes  the  swallowing  of  these  a  matter  of  great  frequency;  and  even  in 
older  children  the  slipping  of  fruit-stones,  pieces  of  bone,  pins,  and  many 
other  substances  into  the  gullet  and  downward  is  not  uncommon.  The 
danger  of  these  being  arrested  in  the  esophagus  and  stomach  has  already 
been  referred  to  (pp.  695  and  717). 

Symptoms. — In  the  intestine  a  foreign  body  causes,  as  a  rule, 
little  trouble.  It  advances  steadily  to  the  rectum  and  is  expelled,  its 
presence  perhaps  producing  slight  pain  or  abdominal  discomfort  or  tender- 
ness. This  applies  only  to  objects  of  moderate  size,  smooth,  and  of 
regular  contour.  Others  may  occasion  severe  pain  and  much  intestinal 
irritation,  and  the  passage  of  feces  containing  visible  or  occult  blood;  or 
they  may  even  perforate  the  intestinal  wall;  or  there  may  be  obstinate 
vomiting  if  the  article  is  of  a  size  and  nature  to  produce  intestinal  obstruc- 
tion. Articles  of  small  size  sometimes  become  lodged  in  the  appendix 
and  may  even  l^e  the  cause  of  perforation  here.  As  a  rule,  however, 
objects  in  the  intestine,  even  if  of  irregular  shape,  travel  on  to  the  rectum 
and  are  passed  in  the  natural  way. 

In  the  rectum  foreign  bodies  produce  no  symptoms  in  most  cases,  but 
sometimes  may  be  the  occasion  of  pain  there,  or  of  tenesmus.  Occa- 
sionally they  enter  the  rectum  through  the  anus,  either  by  accident  or 
having  b^en  inserted  by  the  patient.  This  is,  however,  very  unusual  in 
children. 

In  the  class  of  foreign  b(jdies  are  to  be  included  large /ecaZ  concretions, 
which  ma}'  attain  such  a  size  when  in  the  colon  that  they  are  readily 
felt  through  the  abdominal  wall  and  may  be  the  cause  of  intestinal  ol)- 
struction;  or,  when  in  the  rectum,  may  be  passed  with  great  difficulty  or 
only  with  extraneous  aid.  Small  fecal  concretions,  greatly  resembling 
date-stones  in  shape,  are  not  infrequently  found  in  the  appendix,  and  are 
often  mistaken  foi"  ol)jects  which  have  been  swallowed. 

Prognosis. — ^The  prognosis  of  a  foreign  body  in  the  intestinal  canal 
is  in  general  good.  In  cases  where  the  body  is  large,  or  possesses  siiarp 
I)oints  or  etlgcs,  the  piognosis  must  be  guarded  until  the  object  has  passed 
the  anus.  If  it  enters  the  appendix  it  is  unlik(>ly  to  reenter  the  intestine. 
It  is  possible  that  in  this  situation  it  may  cause  no  tr<)ui)le,  l)ut  it  is  in  a 
degree  a  menace.  In  the  intestine  the  body  may  remain  for  a  few  days  to 
a  week  or  occasionally  decidedly  longer. 

Diagnosis. — ^Tiiis  is  to  be  based  upon  an  unquestionable  history 
of  the  swallowing  of  an  object,  and  on  the  probability  that  it  has  left  the 
stomach.  A  careful  watch  should  be  kept  upon  all  the  passages  from  the 
bowel;  the  stools  being  thoroughly  sluik(>n  with  water  until  soluble,  and 
then  strained  in  the  search  for  the  article.  The  use  of  the  Ki'intgen  ray 
is  invaluable  in  the  case  of  an  object  opa(}U(!  to  it,  to  (leterinin(>  the  j)()si- 
tion  of  this  and  whether  or  not  it  is  passing  downward  in  a  normal  manner. 
Sometimes  palpation  of  the  abdominal  wall  may  reveal  the  presence  of  a 
body  if  favoraiily  situated  for  this  investigation.  This  is  especially 
true  of  fecal  concretions. 

As  far  as  subjective  symptoms  are  concerned,  diagnosis  is  more  un- 
certain. In  children  old  enough  to  be  influenced  by  suggestion,  the  alarm 
of  and  the  (luestioning  l)y  the  parents  may  readily  elicit  complaint  of  a 
purely  hysterical  nature,  referred  to  various  parts  of  the  abdomen.  If 
the  trouljle  is  in  the  rectum  there  ni;iy  be  tenesmus. 

52 


818  THE  DISEASES  OF  CHILDREN 

Treatment. — This  must  be  expectant  at  first,  and  in  emergency, 
surgical.  The  giving  of  starchy  food,  such  as  bread,  arrowroot,  oatmeal, 
and  potato,  tends  to  coat  the  body  and  render  its  passage  through  the 
intestine  easier  and  less  harmful.  In  the  case  of  fecal  concretions, 
repeated  administration  of  purgative  drugs  in  small  dose  may  be  needed, 
castor  oil  being  one  of  the  best  of  these.  The  occurrence  of  obstruction 
or  of  sjTnptoms  of  peritonitis  demands  prompt  operative  interference, 
but  this  is  seldom  required.  In  the  rectum  the  body  may  be  sought  by 
digital  exploration  and  by  the  speculum,  and  its  passage  aided;  if  neces- 
sary by  dilatation  of  the  sphincter,  although  this  will  rarely  be  needed. 

MORBID  GROWTHS  OF  THE  INTESTINE 

Rectal  Polypus.^ — -Although  not  a  common  affection  this  is  oftener 
seen  in  childhood  than  at  other  periods  of  life.  It  is,  however,  rare  in 
infancy.  The  growth  is  an  adenoma,  pea-size  or  larger,  of  a  bright-red 
color,  and  usually  single  and  situated  upon  the  posterior,  or  sometimes 
the  anterior,  wall  of  the  rectum,  2  or  3  inches  (5.1  to  7.6  cm.)  above 
the  anus.  There  is  generally  a  pedicle  3^^  to  3  inches  (1.27  to  7.6  cm.)  in 
length,  but  occasionally  the  growth  may  be  attached  to  the  mucous 
membrane   by  a  broad  base.     Sometimes  several  polypi  are  present. 

The  chief  sy^nptom  is  hemorrhage,  with  or  without  the  passage  of 
mucus.  If  the  pedicle  is  sufficiently  long  for  the  polypus  to  approach  the 
anus  there  is  also  discomfort  or  pain  in  the  rectum  and  tenesmus,  and  the 
tumor  may  be  protruded  through  the  anus  during  efforts  at  defecation. 
There  may  also  be  constipation  or,  occasionally  diarrhea,  and  sometimes 
symptoms  of  nervous  disturbance. 

The  diagnosis  is  to  be  made  only  from  hemorrhage  from  other  causes 
and  from  prolapse  of  the  rectum;  and  careful  examination  readily  shows 
the  differences.  Treatment  consists  in  removing  the  growth  by  operative 
measures.     A  return  of  the  trouble  is  unusual. 

Other  Morbid  Growths. — These  are  of  great  rarity  in  early  life. 
The  most  common  is  sarcoma,  which  may  be  either  primary,  or  secondary 
to  the  disease  in  other  regions.  Nobecourt^  was  able  to  collect  but  13 
cases.  Fibroma,  angioma,  lipoma  and  cysts  have  also  been  found.  The 
lymphoid  growths  of  leukemia  may  also  occur  in  this  locality;  and 
Zuppinger^  has  collected  12  instances  of  carcinoma,  including  1  reported 
by  himself. 


CHAPTER  VIII 
INTESTINAL   PARASITES 

The  diagnosis  of  "worms,"  as  made  by  the  laity  and  frequently  by 
physicians,  is  certainly  oftener  a  mistaken  than  a  correct  one.  Although 
still  common  enough,  the  frequency  of  the  occurrence  of  intestinal  worms 
has  unquestionably  diminished  greatly.  All  sorts  of  symptoms  are 
attributed  to  their  supposed  presence,  but  only  the  actual  finding  of  the 
parasites  or  their  ova  justifies  the  diagnosis. 

1  Trait6  des  mal.  de  I'enfance,  1904,  II,  257. 

2  Wien.  klin.  Wochenschr.,  1900,  XIII,  389. 


ASCARIS  LUMBRICOIDES 


819 


ASCARIS  LUMBRICOIDES 

(Round  Worm) 

This  nematode  worm  is  perhaps  the  most  common  intestinal  parasite 
in  children  in  this  country,  with  the  single  exception  of  the  hook-worm  as 
encountered  in  certain  districts.  From  various  statistics  collected  by 
Lechler^  its  occurrence  would  appear  to  be  most  fre- 
quent from  5  to  10  years  of  age.  It  is  rarely  seen  in 
infancy.  Perhaps  the  youngest  recorded  case  was  in 
an  infant  of  3  weeks,  reported  by  Miller.^  The  total 
incidence  of  the  disease  is  subject  to  wide  variation 
with  the  geographical  locality.  Lechler's  review 
shows  a  range  of  from  2.33  per  cent,  to  43.33  per  cent, 
of  the  children  examined.  The  ascarides  occupy 
especially  the  small  intestine,  from  which  they  may 
pass  downward  and  be  voided  from  the  rectum,  or 
they  occasionally  wander  in  other  directions.  Not 
infrequently  they  enter  the  stomach  and  may  be 
vomited.  They  may  also  find  their  way  into  the 
larynx,  causing  asphyxia;  the  Eustachian  tube;  the 
nose;  tonsils;  the  trachea  and  thence  into  the  lung; 
the  bile  duct  and  thence  the  liver,  where  they  have 
produced  abscess;  the  pancreatic  duct;  the  vermiform 
appendix,  and  Meckel's  diverticulum,  in  the  last 
perhaps  being  discharged  from  an  umbilical  fistula. 
Very  rarely  the  worms  may  perforate  ulcers  in  the 
intestine  and  enter  the  peritoneal  cavity,  causing 
peritonitis,  and  ca.ses  have  been  published  in  which 
even  the  healthy  intestinal  or  gastric  walls  are  said 
to  have  been  completely  penetrated.  Plew^  has 
studied  this  occurrence,  with  the  report  of  a  case  and 
a  review  of  the  literature.  When  in  very  large 
numbers  they  may  occasionally  produce  intestinal 
obstruction.  Of  this  rare  occurrence  Doberaner'* 
has  collected  24  instances.     (See  Fig.  257.) 

The  round  worm  bears  a  close  resemblance  in 
form  to  the  ordinary  earth-worm,  but  is  of  a  pinkish 
color  and  of  larger  size,  being  from  y^  to  over  yi  of 
an  inch  (0.32  to  0.()4  cm.)  in  thickness,  and  the  male 
from  4  to  8  inches  (10  to  20  cm.)  and  the  female 
from  7  to  12  inches  (18  to  31  cm.)  in  length  (Fig.  2(35). 
The  eggs,  which  are  produced  by  the  million,  are 
round  or  oval,  brownish  or  yellowish  in  color,  about 
Koo  of  ^^  ir'f'h  (0.005  cm.)  in  the  greatest  diameter  and 
with  a  nodular  outer  coat.  The  number  of  worms 
ordinaiily  present  in  the  intestine  is  usually  not  large, 
prolxibly  not  exceeding  from  5  to  20,  but  after  a 
vermifuge  they  may  occasionally  be  passed  in  hanti- 
fuls  and  mniiber  even  hundreds.  The  eggs  enter  the 
body  through  the  mouth,  having  contaminated  the 
drinking  water  or  uncooked  vegetables  or  fruits   which  have  come  in 

'  Arch.  f.  Kirulorh.,  lOl.'i,  XLII,  49. 

-  .lahrb.  f.  Kinderh.,  189.5,  XXXVI,  319. 

3  .Vrch.  f.  Kinderh.,  1913,  LXII,  11. 

*  Prag.  med.  Wochenschr.,  1914,  XXXIX,  197. 


I'"k;.      2t').").—  .\srARi.s 

LlMHKiroIDKS. 

()iu--h(ilf  iiiitural  sire. 


820  THE  DISEASES  OF  CHILDREN 

contact  with  human  feces,  perhaps  in  the  form  of  manure.  They  de- 
velop in  the  intestine  and  are  mature  in  the  course  of  a  month.  It  is 
generally  believed  that  no  intermediate  host  is  required,  but  that  the 
eggs  do  not  develop  into  embryos  until  they  have  been  passed  from  the 
bowel  and  enter  again  by  the  mouth.  Ransom  and  Foster^  think  no 
intermediate  host  is  necessary,  but  that  the  worms  as  soon  as  hatched 
migrate  to  other  organs,  including  the  lungs,  and  thence  enter  the 
trachea,  esophagus  and  finally  the  intestine,  where  they  complete  their 
development;  while  Stewart^  maintains  that  rats  and  mice  act  as 
intermediate  hosts. 

Symptoms. — As  a  rule  there  are  none  whatever  and  the  diagnosis 
can  be  made  only  by  the  discovery  of  the  worms  or  their  ova  in  the  passages. 
Sometimes  there  are  produced  the  symptoms  characteristic  of  many 
digestive  disturbances,  such  as  irritability,  restless  sleep,  grinding  of  the 
teeth,  picking  of  the  nose,  colic,  tympanites  and  loss  of  appetite;  but 
these  are  much  more  frequently  dependent  upon  other  causes  than  upon 
the  presence  of  the  ascarides.  Various  nervous  manifestations  are  often 
attributed  to  the  parasites,  and  are  sometimes  actually  due  to  them  when 
they  occur  in  large  numbers,  as  proven  by  the  fact  that  their  removal 
by  treatment  may  be  followed  by  cessation  of  the  disturbance.  Among 
the  assigned  symptoms  are  attacks  of  fever,  convulsions,  choreiform 
movements,  vertigo,  headache,  meningeal  symptoms  and  anemia.  It 
is  possible  that  these  are  the  result  of  the  absorption  of  toxins  produced 
by  the  parasite.  An  eosinophilia  is  generally  present  in  the  blood.  The 
only  serious  symptoms  are  those  seen  in  the  rare  instances  referred 
to  where  a  large  mass  of  worms  have  occasioned  intestinal  obstruction; 
or  where  they  have  wandered  into  distant  regions.  The  nature  of  these 
more  remote  disturbances  depends,  of  course,  upon  the  locahty  invaded. 

Treatment. — This  is  usually  very  efficacious.  The  most  popular 
and  serviceable  remedy  is  santonin  in  powdered  form,  combined  with 
calomel  or  sugar,  and  given  in  doses  of  1 2  to  1  grain  (0.032^to  0.065)  to  a  child 
4  or  5  years  of  age,  3  tunes  a  day,  for  1  or  perhaps  2  days.  The  patient 
should  be  prepared  foi-  the  treatment  by  short  starvation  or  the  use  of  a 
milk-diet  for  a  day  or  two,  and  a  dose  of  castor  oil  or  other  purgative 
should  be  given  after  the  course  of  santonin  has  been  completed.  When 
given  with  calomel,  }i,  grain  (0.032)  of  this  to  the  dose,  the  castor  oil 
will  probably  not  be  required.  It  is  important  to  obtain  purgation  after 
the  administration  of  santonin  in  order  to  remove  it  from  the  system,  or 
it  may  be  absorbed  and  xanthopsia,  or  "yellow  vision"  result,  with  head- 
ache, vomiting,  vertigo  and  even  convulsions.  Another  remedy  some- 
times employed  is  fluid  extract  of  spigelia  and  senna,  1  fluidram  (4) 
at  4  years  of  age,  given  3  times  a  day  for  2  or  3  days.  Oil  of  cheno- 
podium,  5  minims  (0.31)  on  sugar  at  4  years  of  age,  administered  3 
times  a  day,  is  also  serviceable.  Caution  must  be  observed  against  an 
overdose.  A  couple  of  weeks  after  treatment  with  any  vermifuge  the 
stools  should  be  examined  for  ova  and  the  treatment  repeated  if  these 
aie  found  to  be  present. 

OXYURIS  VERMICULARIS 
(Thread-worm.     Pin-worm) 

The  oxyuris  is  a  nematode  worm  seen  much  most  frequently  in  chil- 
dren, but  is  by  no  means  confined  to  this  age.  I  have  found  the  worms 
in  a  man  of  70  years  who  had  suffered  froiri  them  for  an  unknown  period 

1  Journ.  Agricult.  Research,  1917,  XL,  395. 

2  Parasitology,  1916-17,    IX,  157. 


OXYURIS  VERMICULARIS  821 

in  spite  of  repeated  treatment  for  their  removal.  They  are  less  often 
encountered  in  infants.  A  lack  of  cleanliness  seems  to  predispose,  but 
this  does  not  appear  to  be  essential.  Trumpp^  reported  that  in  ]\Iimich 
30  per  cent,  of  the  children  examined  showed  the  eggs  or  the  worms 
themselves  in  the  feces.  The  parasites  inhabit  the  rectum  and  large 
intestine,  the  majority  being  found  in  the  cecum;  but  they  are  not  con- 
fined to  this  part  of  the  gut,  and  in  any  event  appear  to  enter  it  from  the 
small  intestine,  which  seems  to  be  their  breeding  place.  They  are  not 
infrequently  discovered  in  the  vermiform  appendix  and  have  occasion- 
ally been  found  in  the  stomach  and  even  the  mouth.  Not  rarely  they 
wander  into  the  vagina  or  under  the  prepuce,  occur  in  the  groins  and 
about  the  genitals,  and  examination  will  generally  reveal  them  in  the 
folds  about  the  anus. 

In  appearance  the  oxyuris  resembles  a  very  short  white  thread  (Fig. 
266).  The  female  measures  from  V4  to  }4  inch  (0.64  to  1.27  cm.)  in  length 
and  about  I25  inch  (0.1  cm.)  in  thickness;  the  male  not  more  than  J-i  or 
1^  of  this  size.  In  the  intestines  they  are  present  in  vast  numbers,  cover- 
ing thickly  the  walls  of  the  rectum,  and 
l)eing  embedded  in  the  mucus  coating  it. 
The  number  of  worms  passed  is  sometimes 
enormous.  The  eggs  are  produced  in  the 
bowel  in  large  quantity,  l)ut  are  not  al- 
waj'S  readily  discovered  in  the  stools.  They 
are  white  in  color,  oval  in  shape  but  asym- 
metrical,    with    a      smooth    exterior,    and 

measure  approximately  Hoo  inch  (0.005  ^^^  266-Oxyiris  Veiuhcl- 
cm.)  in  length  and  igoo  inch  (0.0032   cm.)  laris. 

in  diameter.     The  chikh-en  constantly  rein-  Natural  size, 

feet  themselves  and  other   children    in   the 

family  by  transmitting  by  the  hand  the  eggs  which  have  lodged  under  the 
finger  nails  in  the  act  of  scratching  at  the  anus;  or  the  eggs  may  come  into 
contact  with  raw  food,  toys,  dust,  and  the  like.  Thus  introduced  they 
develop  into  fully  matured  worms  in  the  small  intestine,  and  these  may  be 
found  in  the  feces  in  2  to  3  weeks.  No  intermediate  host  is  required.  It 
is  generally  believed  that  eggs  produced  in  the  intestine  will  not  develop 
there  until  reintroduced  by  way  of  the  mouth.  This  is,  however,  denied 
by  Trumpp. 

Symptoms. — The  principal  syni])toni  is  intoleral)le  itching  at  the 
anus,  usually  woi'se  at  night-time  and  interfering  greatly  with  sleep.  Ex- 
amination may  reveal  the  living  and  moving  worms  in  small  or  in  great 
numbers  coating  the  stools,  or  within  the  anus  if  the  mucous  membrane 
is  slightly  everted,  or  even  in  the  folds  of  the  groin  or  about  the  genitals. 
The  giving  of  an  enema  will  often  bring  away  large  nund)ers  of  the  para- 
sites from  the  bowel.  The  scratching  which  the  itching  incites  often 
produces  a  secondary  eczema  about  the  anus.  If  the  worms  have  en- 
tered the  vagina  vulvovaginitis  r(>sults.  and  the  intense  itching  may 
induce  masturbation.  Other  .secondary  symptoms  often  appear,  among 
them  being  (Miuresis.  fi-e(|ueiit  micturition,  prolapse  of  the  rectum  Ironi 
straining,  and  (catarrhal  infl:immation  of  the  colon  and  rectum  with  dis- 
chaige  of  a  large  amount  of  mucus.  More  remote  symptoms  sometimes 
result  from  the  irritation  and  the  lo.ss  of  rest,  sucii  as  night-terrors, 
anemia,  dei)ility.  and  even  convulsions.  Eosinophilin  is  .•in  uncertain 
sj'inptom.  present  in   '  •_>  <>i"  less  of  the  cases. 

»Zcitsthr.  f.  Kiiidcrli.,  Orin.,  l"->i;i,  \1.  -'Oo.' 


822  THE  DISEASES  OF  CHILDREN 

Course  and  Prognosis. — -The  prognosis  is  good  in  many  cases, 
when  the  worms  are  present  in  small  numbers  and  the  irritation  slight. 
Here  local  measures  may  suffice.  The  great  difficulty,  however,  which 
often  renders  successful  treatment  a  puzzling  problem,  is  the  constant 
danger  of  reinfection  when  the  worms  are  numerous  and  the  itching  severe. 
The  impulse  to  scratch,  which  the  child  cannot  resist  and  which  takes 
place  unconsciously  at  night,  and  the  presence  of  numerous  ova  on  the 
cutaneous  surfaces  in  the  neighborhood  of  the  anus  and  even  upon  the 
nightdress  and  bed-clothing,  render  the  transference  to  the  mouth 
almost  inevitable  unless  means  are  taken  to  prevent  this.  The  fact, 
too,  that  local  treatment  by  means  of  injection  does  not  reach  the  upper 
colon  satisfactorily  or  the  small  intestine  at  all,  adds  to  the  difficulty 
in  curing  severe  cases,  and  renders  the  disease  obstinate  and  the  course 
prolonged. 

Treatment.— This  consists  in  (a)  destroying  byenemata  in  the  rec- 
tum the  female  worms  which  are  about  to  discharge  their  eggs;  (6)  the 
administration  of  remedies  by  the  mouth  which  will  kill  the  worms  in 
the  small  intestine  or  upper  colon;  (c)  the  destruction  of  the  eggs  which 
have  been  deposited  on  the  skin  of  the  ano-genital  region  and,  by  the 
relief  of  itching  and  in  other  ways,  the  prevention  of  the  carrying  of  them 
to  the  mouth  of  the  patient  with  consequent  reinfection. 

(a)  The  first  purpose  is  well  served  by  the  injection  of  an  enema  of 
infusion  of  quassia  as  high  as  possible  into  the  colon  with  the  hips  ele- 
vated, using  from  a  pint  (473)  to  a  quart  (946)  of  liquid.  This  should  be 
given  every  evening  at  bedtime  for  from  7  to  10  days.  Success  may  be 
obtained  also  with  large  flushings  with  simple  cold  water  or  soap-water. 
Salt  and  water  (1  ounce  :  1  pint)  (28:473),  infusion  of  garlic,  turpen- 
tine, vinegar,  and  corrosive  sublimate  (1  :  10,000)  are  also  recommended, 
but  those  which  are  neither  irritating  nor  poisonous  in  nature  are  to  be 
preferred.  For  worms  or  eggs  in  the  vagina  the  bichloride  injection  may 
well  be  employed. 

(6)  To  reach  the  worms  situated  higher  in  the  bowel  various  drugs 
have  been  recommended  for  administration  by  the  mouth.  Santonin, 
spigelia  or  chenopodium  may  be  given  as  for  ascarides.  Naphthalene  has 
been  used  by  many,  administering  it  in  doses  of  }^4,  to  1  gr.  (0.032  to 
0.065)  3  or  4  times  a  day  at  2  years  of  age,  and  continuing  for  a  week, 
the  course  being  repeated  after  a  period  of  2  weeks.  Oily  substances 
should  be  withheld  while  this  drug  is  being  employed.  Saline  purgatives 
alone  are  excellent,  citrate  of  magnesia  often  being  taken  readily  by  chil- 
dren.    Any  remedy  employed  is  best  given  after  a  period  of  fasting. 

(c)  Preferably  after  every  bowel  movement,  and  certainly  morning 
and  night,  the  whole  ano-genital  region  and  surrounding  parts  should  be 
bathed  with  a  1  :;10,000  bichloride  solution.  The  necessity  of  the  daily 
changing  and  thorough  disinfection  of  the  bedding  and  night-clothes  is 
to  be  borne  in  mind.  The  hands  of  the  nurse  and  of  the  patient  must  be 
'kept  disinfected;  the  dirt  beneath  the  finger-nails  where  the  eggs  are  so 
often  embedded  removed  carefully;  and  at  night,  and  possibly  in  the  day 
also,  the  hands  mechanically  hindered  from  contact  with  the  anus  or  the 
mouth,  as  by  the  wearing  of  mittens  or  other  protective  covering  or  of  a 
pasteboard  elbow-cuff  which  prevents  flexion  of  the  joint,  or  by  dress- 
ing the  child  at  night  in  close-fitting  drawers.  To  relieve  the  itching 
and  lessen  the  tendency  to  scratching,  boric-acid  ointment  or  mercurial 
ointment  may  be  applied  to  the  anus,  especiallj^  at  bedtime.  This  has 
the  additional  advantage  of  being  destructive  to  the  eggs  and  worms. 


TMNIA  823 

It  must  be  remembered  that  the  disease  is  very  contagious  and  that  other 
children,  or  even  adults,  of  the  family  may  be  sufferers  from  it.  To  cure 
any  patient  it  is  therefore  necessary  that  in  the  prevention  of  reinfection 
all  sources  of  family-infection  must  be  considered,  and  all  those  infected 
must  be  treated. 

T^NLA. 
(Tapeworm) 

These  cestode  worms  are  of  common  occurrence  in  early  Ufe,  their 
frequency  probably  equalhng  that  in  adults.  In  9000  children  in  Den- 
mark Schiodte^  found  tapeworm  in  43.  To  this  statement  infancy  offers 
a  decided  exception,  tapeworms  of  most  species  occurring  at  this  period 
only  under  unusual  circumstances,  perhaps  dependent  upon  departure 
from  the  ordinary  diet  of  milk.  The  youngest  cases  recorded  in  medical 
literature  appear  to  be  in  2  infants  of  5  days  (Miiller)^  and  4  days  (Armor) ^ 
respectively,  but  with  our  knowledge  of  the  life-history  of  the  parasite 
such  an  occurrence  seems  scarcely  credible.  Taenia  solium  is  reported 
by  Pardo'*  in  an  infant  of  5  months,  and  taenia  saginata  by  Comby^ 
in  one  of  9  months. 

The  abode  of  the  tapeworm  is  the  small  intestine,  from  which  seg- 
ments pass  into  the  large  intestine  and  are  voided  with  the  stools.  The 
worm  is  of  variable  length,  depending  upon  the  species,  and  is  composed 
of  a  series  of  flattened,  white,  opaque  segments  {^proglottides)  more  or 
less  rectangular  in  form  and  each  sexually  complete.  The  head  (scolex) 
is  the  size  of  a  small  pinhead,  and  is  followed  by  a  thread-like  neck, 
and  this  by  the  youngest  segments,  at  first  very  small.  These  rapidly 
increase  in  size,  until  mature  in  from  3  to  33^^  months,  when  those  toward 
the  lower  end  of  the  worm  separate  and  are  discharged  from  time  to  time, 
singly  or  in  short  series,  new  segments  being  produced  by  the  head.  The 
worm  retains  its  position  in  the  bowel  by  means  of  the  hooks  or  the  suck- 
ers with  which  the  head  is  provided.  The  ripe  segments,  as  passed, 
contain  the  eggs,  which  vary  in  size,  shape  and  number  with  the  species, 
and  which  exhibit  the  embryos  within  them  on  microscopic  examination. 
The  number  of  tapewomis  present  varies  with  the  species.  Sometimes 
2  or  even  3  different  species  of  tapeworm  may  be  found  present  simul- 
taneously in  the  intestine,  but  this  is  unusual. 

The. tapeworm  needs  an  intermediate  host  in  order  to  reproduce  it- 
self, the  species  of  animal  depending  upon  the  species  of  worm.  The 
proglottides  of  the  worm  after  passing  from  the  intestine  soften  and  the 
eggs  are  discharged,  or  in  the  case  of  taenia  solium  the  eggs  may  be  thus 
set  free  before  they  leave  the  intestine.  These  are  then  swallowed  by 
some  animal,  penetrate  its  intestine,  and  develop  in  the  muscles  and  other 
tissues  into  the  larval  form  of  the  worm;  in  the  case  of  the  true  ta^ni- 
idae,  the  cijsticerciis.  The  flesh  of  the  animal  after  it  is  eaten  by  man 
sets  free  the  larvae  in  the  intestine,  where  they  develop  into  tapeworms. 
The  eating  of  the  flesh  containing  these  is  not,  however,  absolutely  neces- 
sary, since  drinking  water  contaminated  by  them  may  produce  the  dis- 
ease.    Such  a  method  of  infection  is,  however,  rare.     In  the  case  of 

1  HospitaLstidcnde,  1902,  X,  1211. 

2  Correspond!)!,    d.    Wiirtomhurg.    iirztl.   Verein,    1837,    VII,   80.     Ref.,    Grimm, 
Miinch.  mod.  Wochenscihr.,  1914,  LXI,  1780. 

•^  New  York  Mod.  .lourii.,  1871,  XIV,  G18. 

*  Soe.  Ginec.  lOspan.     Ilef.,  Grimm. 

*  Archiv  de  m6d.  des  enf.,  1911,  XIV,  52.5. 


824 


THE  DISEASES  OF  CHILDREN 


taenia  elliptica  infected  insects  are  eaten  unconsciously  and  the  larvae 
ingested  in  this  way. 

The  tapeworms  usually  infecting  human  beings  are  of  several  varie- 
ties, the  principal  being  taenia  solium,  taenia  saginata  or  mediocanellata, 
taenia  elliptica  oreucumerina,  taenia  nana,  andthedibothriocephaluslatus. 
Taenia  Solium;  Pork  Tapeworm. — To  this  the  name  of  armed  tape- 
worm is  also  applied,  from  the  double  row  of  hooklets  which  sur- 
rounds the  proboscis.  There  are  also  4 
sucking  mouths.  The  adult  worm  measures 
6  to  12  feet  (183  to  365  cm.)  in  length, 
the  segments  averaging  about  3^^  inch  (1.27 
cm.)  in  length  and  J^  to  ^^  inch  (0.64  to 
0.85  cm.)  in  breadth.  The  ripe  segmensd 
toward  the  end  of  the  worm  are  longer  ant 
narrower.  The  proglottides  contain  in 
their  interior  the  dendritic  uterus  with  8 
to  12  rather  thick  lateral  branches  on  each 
side.  The  eggs  are  brown,  spherical,  and 
about  y-sQo  inch  (0.0032  cm.)  in  diameter. 
This  tapeworm  is  acquired  by  eating  the 
raw  or  imperfectly  cooked  "measly"  flesh  of 
the  hog.  Owing  to  the  peculiarity  of  the 
taenia  solium,  that  the  eggs  are  often  freed 
from  the  proglottides  in  the  intestine  and 
passed  by  stool,  patients  may  occasionally, 
through  uncleanly  habits,  reinfect  themselves 
by  swallowing  the  eggs  and  in  this  way 
develop  the  cysticercus  in  various  parts  of 
the  body.  Taenia  solium  is  very  much 
less  common  in  this  country  than  is  the 
taenia  saginata,  smaller  in  size,  and  is  quite 
infrequent  in  children.  It  occurs  almost 
always  only  singly  in  the  intestine. 

Taenia  Saginata;  Taenia  Mediocanellata; 
Beef  Tapeworm  (Fig.  267). — The  head  is 
larger  than  in  the  preceding  species, 
pear-shaped,  with  4  sucking  mouths,  but 
not  provided  with  hooklets  or  a  beak. 
This  tapeworm  measifres  15  to  24  feet  (456  to 
730  cm.)  or  more  in  length,  %  to  %  of  an 
inch  (1.5  to  2  cm.)  in  length  and  about  ^^ 
inch  (0.  85  cm.)  in  breadth.  Toward  the 
middle  of  the  worm  the  breadth  is  greater 
than  at  other  parts.  The  uterus  contains 
20  to  25  slender  branches  on  each  side,  and 
the  eggs  are  oval  and  measure  ^^oo  to  3^^oo 
of  an  inch  (0.0032  to  0.004  cm.)  in  length 
by  somewhat  more  than  half  this  in  breadth. 
The  worm  is  acquired  by  eating  the  affected  "measly  "  flesh  of  cattle  which 
have  themselves  become  diseased  by  ingesting  the  eggs  of  tapeworms  upon 
vegetation  which  had  come  in  contact  with  contaminated  human  manure. 
One  or  several  worms  may  be  present  in  the  intestine  at  the  same  time. 
This  species  is  very  widely  distributed  geographically,  and,  although 
less  common  in  the  United  States  than  in  many  other  regions,  it  is  by  far 


Fig.     267. — T^nia     Saginata 
Different    portions     of 
Natural  size. 


worm. 


T^NIA 


825 


the  most  frequent  variety  found.  It  is  rare  in  infants,  but  is  occasionally 
acquired  through  the  giving  of  scraped  raw  meat.  I  have  observed  the 
disease  developing  from  this  cause  in  several  instances  under  2  years  of 
age. 

Taenia  Elliptica  or  Cucumerina;  Dog  Tapeworm  {Dipylidium 
caninum). — This  is  a  small  tapeworm  common  in  the  dog  and  cat,  but 
rare  in  the  human  race.  Zschokke^  collected  36  published  cases,  to 
which  he  added  another;  and  Lins'  raised  the  total  number  of  reported 
cases  to  68.  The  majority  of  instances  of  tapeworm  of  this  variety  have 
been  observed  in  children  and  infants.  Usually- 
the  parasite  occurs  singly,  but  Lins  found  from  20 
up  to  200  present  at  a  time.  The  second  host  is  the 
louse  and  the  flea  infecting  dogs  and  cats,  as  well 
as  the  human  flea.  The  close  contact  which  play 
often  brings  with  these  domestic  animals,  and  the 
natural  tendency  of  the  infants  to  put  their  hands  to 
their  mouths,  allows  of  the  swallowing  of  the  infected 
insect  and  the  subsequent  later  development  of 
the  tapeworm.  This  worm  is  slender  and  measures 
only  4  to  12  inches  (10  to  31  cm.)  in  length.  The 
head  is  armed  with  booklets  and  a  beak.  The  pro- 
glottides are  from  }i  to  ^^  inch  (0.85  to  1.27  cm.)  long 
and  a})out  }i  as  broad.  The  eggs  are  about  3^:500  inch 
(0.005  cm.)  in  diameter,  from  6  to  12  being  contained 
in  a  common  capsule. 

Taenia  Flavopunctata;  Rat  Tapeworm  {Hymeno- 
lepsis  flavopunctata). — This  parasite  has  been  rarely 
seen  in  infants  and  chiklren.  It  is  common  in  the 
rat  and  mouse. 

Taenia  Nana;  Dwarf  Tapeworm  {Hymenolepsis 
nana)  (Fig.  268). — This  is  another  variety  of  tape- 
worm which  has  been  thought  to  be  rare  in  this 
country,  although  more  common  in  Italy.  Ransom^ 
collected  in  1904,  106  published  cases  occurring  in 
man.  The  parasite  is  probably  much  more  frequent 
than  these  figures  represent,  inasmuch  as  Amesse'* 
count('<l  68  cases  observed  and  reported  in  America; 
Greil'^  discovered  it  in  5.75  per  cent,  of  6()5  children 
in  Alabama,  ascarides  being  found  in  but  4.06  per 
cent.;  and  Schloss''  found  it  present  in  14  out  of  230 
children  examined  (6.08  per  cent.).  Its  most  frequent 
habitat  is  the  small  intestine  of  species  of  rats  and 
mice.  The  parasite  is  only  J2  to  1  inch  (1.27  to  2.54 
cm.)  long,  and  has  a  spherical  armed  head,  and  150  or  more  short  mikI 
broad  proglottides  each  containing  80  to  100  eggs.  It  occurs  cliicfly  in 
ciiildreii  and  often  in  very  large  numbers  in  a  shigle  case.  Even 
nurslings  may  Ix;  affected.  The  intermediate  host  is  unknown,  and  it 
is  possible  tiiat  none  exists,  but  that  the  larva  occupy  the  mucous  mem- 
brane of  the  intestine  and  there  develop  into  the  perfect  worm. 

'  CcntiMll.l.  f.  li.'ict.  u.  I'.ir.isitcnk.,  Orin-,  Ht<)">,  XXWIII,   .%M. 

-  Wicn.  Klin.  W'ocli..  I'.Hi.  XX!V,  i.-)ii.j. 

•^  ruhlic  Ilcillli  Miiil  .M.iriiic  llnsp.  Service,  l'.  S.  llvnieiiifL.il 

*  Colonido  .Med..  I'.lin,  \il.  »»;{. 

^  .Vnier.  .lour.  Dis.  ("liild..  I'.M.').  X.  AM. 

«  .\rcli.  (»f  Ted.,  I'.IK).  XWll.  I(H», 


Fig.  268.— Hymeno- 
lepsis Nana. 
A,  One-half  actual 

size;      B,      enlurncd; 

showing     head      ant! 

suckers.    (Srhloss, 

Arch.nf  P,(iml..  HMO, 

A' A' 17/,   101.) 


I'Mil     Mull.   \...   IS. 


826  THE  DISEASES  OF  CHILDREN 

Dibothriocephalus  Latus;  Fish  Tapeworm. — The  head  of  this  para- 
site is  small,  wedge-shaped,  grooved  on  each  side,  and  unarmed  with  beak 
or  hooklets.  The  proglottides  are  broader  than  long,  measuring  i^  to  ^^ 
inch  (1.27  to  1.52  cm.)  in  breadth  and  but  about  }i  inch  (0.51  cm.)  in 
length.  This  feature  easily  distinguishes  the  parasite  from  other  tape- 
worms. The  sexual  openings  are  on  the  surface  of  the  proglottides  in- 
stead of  at  the  edge  as  in  other  varieties,  and  the  uterus  is  rosette-shaped, 
instead  of  branched.  The  eggs  are  about  3^^oo  inch  (0.006  cm.)  long  and 
3^^  00  inch  (0.004  cm.)  broad,  and  are  characterized  by  a  lid-shaped 
closure  at  one  end.  After  leaving  the  intestine  the  ova  develop  in  water 
into  a  free-swimming  infusorial  organism,  and  then  by  way  of  the  in- 
testine enter  the  muscles  of  certain  species  of  fish,  where  they  remain  as 
unencysted  elongated  larva  of  perhaps  several  inches  in  length,  suggesting 
the  appearance  of  the  fully  developed  worm.  The  eating  of  fish  thus 
infected  produces  the  sexually  active  parasite  in  the  intestine  of  man. 
The  worm  is  25  to  30  feet  (762  to  915  cm.)  or  more  in  length.  It  is  com- 
mon in  certain  regions,  as  Switzerland  and  Scandinavia,  but  rare  in  the 
United  States.  EdsalP  could  find  up  to  1904  but  22  cases  reported  in 
America.  I  have,  however,  seen  it  once  in  the  adult  and  again  in  a  girl 
of  9  years,  both  unpublished  cases. 

Symptoms  of  Tapeworm. — As  a  rule,  tapeworm  produces  no 
symptoms  other  than  the  passing  of  segments  of  the  worm  in  the  stools, 
and  this  constitutes  the  only  positive  diagnostic  evidence.  An  eosino- 
philia  is  witnessed  in  rather  less  than  half  of  the  cases.  In  a  small 
proportion  there  are  various  digestive  disturbances  present,  such  as 
occasional  vomiting,  abdominal  pain  or  discomfort,  excessive  appetite, 
diarrhea,  vertigo,  headache,  and  the  like;  but  in  the  majority  of  these  it 
is  doubtful  whether  the  worm  possesses  any  etiological  relationship. 
This  is  equally  true  of  the  more  distant  reflex  symptoms  which  have 
repeatedly  been  described,  such  as  epileptiform  and  choreiform  conditions. 
The  only  exception  is  the  severe  anemia  of  the  pernicious  type  which 
sometimes  clearly  depends  upon  the  presence  of  the  dibothriocephalus. 

Course  and  Prognosis.^ — It  is  uncertain  how  long  the  presence  of  the 
worm  may  continue.  Certainly  this  may  even  be  for  years,  new  segments 
being  produced  as  the  mature  ones  separate,  the  total  length  of  the  parasite 
being  thus  unaltered.  The  danger  to  the  patient  is  insignificant,  barring 
the  possibility  of  anemia  or  nervous  symptoms  referred  to,  and  the 
chance  of  reinfection  and  the  production  of  cysticercus  in  the  case  of 
the  presence  of  taenia  solium.  The  prognosis  of  cases  subjected  to  treat- 
ment is  on  the  whole  good,  although  repeated  efi"orts  lasting  over  months 
are  sometimes  required  before  final  relief  is  obtained. 

Treatment. ^ — -In  the  way  of  prophylaxis  care  must  be  taken  to 
prevent  infection.  All  meat  eaten  should  be  sufficiently  well-cooked  to 
kill  any  larva  present.  In  the  days  when  the  giving  of  scraped  raw  meat 
to  children  was  common,  the  development  of  the  beef  tapeworm  could 
occur  more  readily.  Careful,  frequent  disinfection  of  the  hands  of  little 
children  and  the  avoidance  of  too  close  contact  with  dogs  and  cats  are 
prophylactic  measures  against  tsenia  elliptica. 

For  the  actual  treatment  of  the  disease  some  vermifuge  is  required, 
but  only  after  a  positive  diagnosis  is  made.  Whatever  this  may  be,  to 
make  the  treatment  effective  the  head  of  the  parasite  must  be  expelled. 
It  often  happens  that  although  no  head  can  be  found,  later  experience 
with  the  case  shows  that  it  clearly  had  been  broken  off  and  passed,  but 

1  Amer.  Med.,  1904,  Dec,  1087 


TMNIA  827 

was  undiscovered.  Should  the  head  have  remained  in  the  intestine  but 
the  rest  of  the  worm  have  been  discharged,  the  elapse  of  about  3  months' 
time  is  required  for  the  maturing  of  segments  which  would  be  revealed 
again  in  the  stools. 

The  treatment  should  follow  a  certain  routine.  The  child  should  re- 
ceive a  light  dinner  and  still  lighter  supper,  such  as  a  bowl  of  broth  or  of 
bread  and  milk.  On  waking  in  the  morning,  an  enema  and  a  saline 
purgative  should  be  given.  The  object  of  this  is  to  empty  the  intestinal 
canal  as  thoroughly  as  possible.  Breakfast  should  be  withheld,  or  consist 
of  a  cup  of  clear  broth  or  beef  tea.  After  the  action  of  the  purgative,  the 
vermifuge  is  administered  in  a  single  dose  or  divided  doses,  and  followed 
in  an  hour  by  castor  oil  or  a  saline  in  sufficient  amount  to  insure  thorough 
emptying  of  the  bowels.  When  the  desire  for  an  evacuation  comes 
the  child  should  be  seated  on  a  full  vessel  of  water  so  that  the  nates  are 
in  contact  with  the  fluid.  In  this  way  the  weight  of  the  worm  is  partially 
supported  and  the  danger  of  the  breaking  off  of  the  head  is  less.  No 
traction  whatever  should  be  made  upon  it  but,  if  it  ceases  to  pass  easily, 
the  nozzle  of  a  syringe  may  be  very  carefully  inserted  into  the  anus  and 
an  enema  given.  After  the  passing  of  the  stool  and  the  parasite  into  the 
vessel  of  water,  this  latter  should  be  rocked  or  stirred  gently  in  order  not  to 
break  the  worm,  and  the  fecial  matter  poured  off;  then  more  water  added 
and  the  process  thus  continued  until  the  worm  is  clean,  after  which, 
still  suspended  in  water,  it  can  be  examined  with  care  for  the  head. 

As  the  remedies  for  tapeworm  are  often  nauseating,  the  child  should 
be  kept  reclining  in  bed  after  taking  them.  So,  too,  as  the  treatment  is 
rather  exhausting,  further  confinement  to  bed  for  a  day  or  two  is  advisable, 
combined  with  the  giving  of  a  light  diet,  principally  milk.  If  it  is  evident 
from  the  number  and  character  of  the  segments  that  the  worm  is  not 
completely  removed,  another  effort  should  be  made  after  an  interval  of 
some  weeks. 

The  number  of  vermifuges  recommended  is  large.  All  of  them-  are 
supposed  to  have  the  property  of  kilhng,  or  at  least  numbing,  the  parasite 
and  thus  releasing  the  hold  of  its  head  on  the  intestine.  One  of  the  most 
popular  and  effective  is  male  fern  (fehx  mas),  of  which  the  oleoresin  or 
the  freshly  prepared  ethereal  extract  iw&j  be  given  in  doses  of  J<>  to  1 
fl.  dram  (1.8  to  3.7)  to  a  child  4  or  5  years  of  age.  This  may  be  made  up 
into  an  emulsion  disguised  as  far  as  possible;  or  in  tlie  ease  of  older 
children  given  in  capsules  holding  15  minims  (0.92)  and  administered 
every  half  hour  until  the  complete  amount  is  taken.  In  some  trouble- 
some cases  success  has  followed  the  employment  of  a  very  light  diet 
for  a  day  or  two,  combined  with  the  repeated  administration  of  turpen- 
tine; then  finally  the  giving  of  the  male  fern  in  the  manner  described. 

Another  very  useful  remedy  is  pomegranite  (granatum),  which  may 
be  given  in  decoction  in  doses  of  i^:4  to  1  H.  oz.  (22.2  to  30)  for  a  child  of 
from  5  to  10  years  of  age.  As  it  is,  however,  of  an  unj)l('asant  taste  and 
liable  to  cause  vomiting,  the  use  of  the  alkaloid  pell(>ti(>rine  is  to  be  pre- 
ferred. I  have  had  good  results  with  a  preparation  of  tliis  (Tanrct's) 
in  some  obstinate  cases  where  male  fern  liad  failed.  Tlie  drug  is  liable 
to  produce  vertigo,  fainting  and  nausea,  and  the  child  should  be  kept  at 
rest,  as  already  advised  whatever  taenicide  is  chosen.  Kousso  is  often 
an  effective,  but  always  a  very  disagreeable  remedy  and  one  liable  to 
cause  vomiting.  Pumpkin-seed  is  safe  and  not  unpleasant  to  take, 
but  is  very  uncertain  in  its  effects.  Its  condensed  extract  is  highly 
praised  by  Langer^  and  others. 

iPfaundler  and  Sfhlossiuaiui,  llaiull).  d.  KiudcMh.,  190G,  II,  1,  230. 


828 


THE  DISEASES  OF  CHILDREN 


Treatment  for  tapeworm  should  not  be  given  to  delicate  children,  or 
those  suffering  from  digestive  or  other  disturbances  of  moment,  until 
the  maladies  have  been  relieved  and  the  general  health  improved. 

UNCINARIA 
(Hook-worm.     Ankylostoma) 

Various  species  of  uncinaria  are  known  to  infect  animals,  but  only 
two  have  the  intestine  of  man  as  their  habitat.  The  first  of  these  is  the 
uncinaria  duodenalis  (anchylostoma  duodenalis),  first  described  by 
Dubini  in  1838.^     Since  then  this  worm  has  been  recognized  as  the  cause 


Fiu.   269.  Fiu.    270. 

Fig.    269. — New-world  Hookworm.     {Uncinaria  Americana.) 
Natural  size:  1.  Male;  2,  female;  3,  the  sanTe- enlarged  to  show  the  position  of  the  anus, 
a;  the  vulva,  v;  and  the  mouth,  m.      {Stiles,  I8th  An7i.  Report  Bureau  of  Animal  Industry. 
1901,  190.) 

Fig.   270. — Four   Eggs  of  the   New-world   Hookworm. 
Eggs  exhibiting  in  the  one-,   two-,  and  four-cell  stages.     The  egg  showing  three  cells 
is  a  lateral  view  of  a  four-cell  stage.      Greatly  enlarged.      {Stiles,  ISth  Ann.  Report  Bureau 
of  Animal  Industry,  1901,  19.3.) 

of  certain  forms  of  anemia,  seen  especially  in  those  working  much  in  earth. 
It  is  very  widespread  in  tropical  and  subtropical  countries  of  the  Old 
World,  although  much  most  frequent  in  certain  regions,  abounding,  for 
instance,  in  Egypt.  In  the  United  States  it  would  seem  not  to  be  of 
common  occurrence,  only  about  35  cases  having  been  recorded  by  Stiles 
up  to  1902.2  Ashford''  was  the  first  to  point  out  the  seriousness  of  anky- 
lostomiasis in  this  country,  finding  it  extremely  common  in  Porto  Rico; 
but  Stiles  in  May,  1902,-*  reported  the  discovery  that  the  hook-worm  of  the 

1  .\nnali  universal!  di  im-dicina,  Milan,  1843,  CVI,  5. 

2  Bull.  No.  10  Hvgicnic  Lah.  C.  S.,  1903,  9. 

3  New  York  Mori.  .Jour..  1900,  Iv.XXI,  5.52. 
^  Amcr.  Mod.,  1902,  III.  777. 


UXCIAARIA 


829 


United  States  was  a  different  species  from  that  seen  in  Europe,  and  named 
it  the  Uncinaria  Americana;  and  studies  of  recent  j^ears  have  shown  that 
uncinariasis  is  one  of  the  most  frequent,  widespread  and  important 
diseases  of  the  Southern  States.  It  prevails  especially  in  rural  districts 
where  the  soil  is  sandy,  and  it  appears  most  common  and  serious  in 
women  and  children.  Greil^  found  it  in  26.75  per  cent,  of  665  children 
under  12  years,  80  of  whom  were  Negroes.  Although  it  affects  especially 
the  poor  and  dirty,  it  is  by  no  means  confined  to  these.  Thus  Gage  and 
Bass^  examined  315  students  at  Tulane  University,  New  Orleans,  and 
found  25  per  cent,  infected  with  hook-worm. 

Uncinaria  Americana  is  a  very  small,  thread-hke  nematode  worm, 
the  female  being  about  l-z  inch  (1.27  cm.)  in  length  and  the  male  slightly 
smaller  (Fig.  269).     Its  buccal  orifice  is  provided  with  a  pair  of  cutting 


I'lL-.    J71.       ri-NtrUATlU-N    Ui'  llli-  .Sk.I.\  lii    L.NCi-NAUlA. 

Some  of  the  parasites  are  seen  already  beneath  the  surface.      {Fcrnll,    Jour.    Anur. 
Med.  .4.s»or.,  1014,  LXII,  1937.) 

plates.  The  numerous  thin-shelled  eggs  are  olliplical  in  shape  ami 
measure  about  I400  to  ^^^50  of  an  inch  (0.006  to  0.007  cm.)  in  length  and 
about  1 2  i»!^  niuch  in  breadth  (Fig.  270).  It  is  characteristic  of  them  that 
they  arc  usually  more  or  less  segmented.  The  uncinaria  duodenalis,  or  Old 
World  hook-worm,  differs  in  being  slightly  longer  and  stouter,  and  in 
having  the  buccal  orifice  armed  with  teeth.  The  eggs  are  slightly  smaller. 
The  life  history  of  the  uncinaria  duodenalis  is  known,  and  that  <)f  the 
uncinaria  Americana  is  prol)ably  the  same.  The  worm  inhabits  the 
small  intestine,  especially  the  duodenum  and  the  jejunum,  and  may 
be  present  in  enormous  numbers.  J^y  its  sucking  apparatus  it  attaches 
itself  to  the  intestiMMJ  mucous  membrane  and  probably  al)stracts  blood 
from  it.     The  head,  by  turning  backward,  gives  the  parasite  the  form 

'  .\incr.  Jour.  Dis.  Cliiid.,  1915,  X,  MV.i. 
2  .\rch.  Int.  M(«(l.,  H»l(),  VI,  :J(W. 


830  THE  DISEASES  OF  CHILDREN 

of  a  hook.  In  shifting  its  position  the  worm  leaves  minute  bleeding 
points.     It  is  likely,  too,  that  it  produces  a  poisonous  substance. 

The  eggs  will  not  mature  within  the  intestine,  but  are  passed  with 
the  feces,  and  enter  moist  ground  or  water  where  they  promptly  develop 
into  the  worm-like  larvae.  These  remain  alive  perhaps  for  months  until 
they  again  enter  the  alimentary  canal,  being  conveyed  by  the  hands 
soiled  by  earth,  or  through  the  swallowing  of  contaminated  water  or 
the  direct  eating  of  earth  according  to  the  habit  of  some  of  the  natives 
{Geophagi).  In  the  intestine  they  finish  their  transformation,  if  suffi- 
ciently well-advanced,  into  the  adult  parasite.  The  larvae  may  also 
reach  the  system  by  penetrating  the  skin  directly  from  without  (Fig.  271). 
Thence  by  way  of  the  circulation  they  reach  the  pulmonary  alveoli. 
From  here  they  migrate  along  the  bronchial  tubes  and  trachea  to  the 
gullet,  and  thence  to  the  esophagus  and  finally  into  the  stomach  and 
intestine  (Looss).^  No  intermediate  host  is  therefore  needed.  The 
worms  very  probably  live  in  the  intestine  for  years.  A  period  of  in- 
cubation of  from  4  to  6  weeks  is  requu-ed  from  the  time  of  the  entrance  of 
the  larvae  before  maturity  is  reached. 

Symptoms. — It  is  likely  that  a  large  number  of  parasites  must  be 
present  to  produce  symptoms.  After  an  initial  gastrointestinal  dis- 
turbance, evidences  of  disease  are  entu'ely  of  a  constitutional  nature, 
and  consist  chiefly  in  the  varied  manifestations  of  anemia,  this  resulting 
from  the  direct  loss  of  blood,  from  the  poison  entering  the  system  from 
the  mouth  of  the  worm,  or  through  the  entrance  of  bacteria  through  the 
wounds.  The  intensity  of  the  symptoms  varies  with  the  case.  In 
well-marked  instances  the  complexion  grows  pale  and  clay-colored,  the 
expression  is  apathetic  and  of  a  peculiar  dullness ;  the  abdomen  is  much 
distended  by  gas  and  sometimes  contains  fluid,  the  liver  and  spleen  are 
enlarged,  the  growth  of  the  body  is  stunted,  emaciation  is  present, 
and  there  may  be  edema,  especially  of  the  face.  Pica,  or  the  habit  of 
eating  dirt  and  the  like,  is  a  common  symptom,  probably  oftener  the 
result  than  the  cause  of  the  disease.  There  may  be  subnormal  or  some- 
times elevated  temperature.  The  blood  exhibits  marked  reduction  of 
the  red  blood-corpuscles  and  especially  of  hemoglobin,  often  to  20  or  30 
per  cent.,  while  an  eosinophilia,  connHonly  of  8  or  10  per  cent,  or  more, 
is  a  very  constant  and  characteristic  sj^mptom. 

Prognosis. — The  prognosis  for  recovery  from  the  disease  is  un- 
favorable unless  treatment  is  instituted.  This  is  especially  true  of 
children.  Yet,  although  many  deaths  occur,  there  is  even  greater  dis- 
position for  the  disease  to  become  chronic  and  to  last  for  years  until 
terminated  by  some  complicating  affection.  Many  adults  show  a  tend- 
ency to  recovery,  if  reinfection  does  not  occur.  Under  treatment  the 
prognosis  is  favorable,  except  in  the  advanced  cases  with  great  debility 
and  anemia. 

Diagnosis.— If  the  disease  is  suspected,  and  examination  of  the 
feces  made,  the  diagnosis  is  easy,  especially  if  treatment  has  been 
recently  given  and  a  large  number  of  eggs  are  passed.  The  segmented 
appearance  of  the  eggs  is  quite  characteristic.  The  presence  of  eosino- 
philia is  also  suggestive.  It  is  important  to  bear  in  mind  that  a  large 
proportion  of  the  cases  supposed  to  be  chronic  malaria,  anemia,  and  the 
like,  are  in  reality  uncinariasis. 

Treatment. — Prophylaxis  consists  in  hygienic  precautions  against 
infection  in  the  districts  where  the  disease  prevails;  these  consisting 

1  Centralbl.  f .  Bakt.  und  Parasit.,  1898,  XXIV,  484. 


OTHER  INTESTINAL  PARASITES 


831 


especially  in  the  frequent  washing  and  disinfection  of  the  hands,  the  dis- 
infection of  the  feces,  the  boiling  of  drinking  water,  and  the  forbidding 
of  the  children  to  run  barefooted.  In  regions  where  the  disease  is  en- 
demic, the  building,  correct  location,  employment,  and  disinfection  of 
properly  constructed  privies  should  be  insisted  upon,  and  the  disinfection 
of  the  ground  about  the  dwelling-houses  accomplished  by  the  application 
of  fire  in  some  way. 

Direct  treatment  is  usually  simple  and  efficacious.  After  a  very  light 
diet  for  24  hours,  thymol  may  be  administered  to  a  total  amount  of  i^ 
fl.  dram  (1.8)  in  divided  doses  to  a  child  of  10  or  12  years,  followed  in  2 
hours  by  a  saline.  No  castor  oil  or  other  fatty  substance  should  be  given 
during  the  treatment.  The  drug  may  be  made  into  an  emulsion  or  put 
into  capsules.  The  feces  should  be  examined  after  a  week  to  see  that 
no  more  eggs  are  present.  If  they  are  still  found,  the  treatment  must  be 
repeated,  or  felix  mas  used  in  the  manner  recommended  for  tapeworm. 
In  weakly  subjects  the  thymol  should  be  administered  in  smaller  and 
more  frequent  doses,  since  the  drug  is 
capable  of  producing  dangerous  symptoms. 
Oil  of  chenopodium  is  recommended  in 
place  of  thymol  by  Levy,'  Bishop  and 
Brosius^  and  others  as  more  efficacious  and 
safer.  The  dose  is  1  drop  (0.062)  on  sugar 
every  2  hours  for  3  or  4  doses  for  each  year 
of  the  child's  age.  The  last  dose  should  be 
followed  in  about  2  hours  by  castor  oil. 
A  saline  laxative  should  be  given  on  the 
day  preceding  the  administration  of  the 
vermifuge.  Hall  and  Foster^  recommend 
chloroform  as  far  superior  to  chenopodium. 
The  adult  dose  is  2  to  3  c.c.  (33  to  49 
m.)  dissolved  in  castor  oil.  After  the  re- 
moval of  the  parasites  tonic  treatment 
directed  to  the  anemia  is  required. 

OTHER  INTESTINAL  PARASITES 

Other    animal    parasites    occurring   in 
the   intestine    are    of    minor    importance. 
Chief  of  them  is  the  trichocephalus   dispar 
or    whipworm,    a    small   slender   nematode 
worm  about  1}^  to  2  inches  (3.81  to  5.08 
cm.)    long,    for    two-thirds    of    its    length 
very  thin  and  thread-like,  and  then  joined 
like  a  whip-lash  to  the  thicker  posterior 
portion,  which  in  the  male  is  rolled  up  like 
a  spring  (Fig.  272).     The  numerous   eggs 
are  lemon-shapod  and  of  al)0ut  the  size  of 
those  of  the  oxyuris — ^--soo  inch  (0.005    cm.)  in  length   and 
(0.0032    cm.)     broad  -but    with    a    plug-like     closure    at 
The  parasite,  seldom  in  large  numlicrs,  inhabits  espoci^illy 
It  is  of  very    common    occurrence    in    some    countries,    less 


2  7  2.  —  Thichockphalcs 
Dispar. 
a,    Male;   h,  female;   c,    eggs. 
(vonJaksch,  Klinische   Diaonontik, 
1887.   150.  Fid.  54.) 


Ksoo    iiH'h 

each    end. 

the  cecum. 

so  in  the 


United    States;    although   Town-send"*    discovered    it    in    the    feces  of 

1  Journ.  Amcr.  Med.  ,\ssoc.,  1914,  LXIII,  194t). 

2  Journ.  Ainer.  Med.  .\s.soc.,  191.'),  LX\\  ItlKl. 
» Journ.  Amer.  Med.  Aasoc,  1917,  LXVIII,  1901. 
*  Amer.  Text-Book  of  Diseases  of  Children.  1894,  553. 


832  THE  DISEASES  OF  CHILDREN 

all  of  16  children  examined.  Neumann'  found  the  parasite  in  the  feces 
of  13.9  per  cent,  of  122  children  of  from  1  to  16  years,  and  it  is  perhaps  as 
often  seen  in  adults.  Christoffersen'  in  200  autopsies  of  various  diseases 
at  all  ages  observed  it  in  29  per  cent.  It  is  often  associated  with  other 
worms,  especially  the  asearis.  The  ova  develop  in  water  or  damp  earth, 
and  are  thence  taken  by  accident  into  the  stomach.  There  are  practically 
no  symptoms,  except  it  may  be  diarrhea  or  anemia  as  reported  in  some 
instances.  Treatment  is  unsatisfactory,  the  worms  seeming  to  be  almost 
impossible  to  remove  by  the  use  of  drugs.  Various  protozoa  and  in- 
fusoria are  from  time  to  time  found  in  the  intestinal  canal  in  children, 
among  them  the  Ameba  coll,  the  Cercomonas  intestinalis,  the  Trichomonas 
intestinalis,  the  Balantidium  coli,  and  the  Megastofnum  entericum.  They 
are  recognized  by  microscopical  examination  of  the  stools,  but  for  details 
of  their  appearance  reference  must  be  made  to  works  especially  devoted  to 
this  subject.  They  ordinarily  produce  no  symptoms,  but  it  is  to  be  noted 
that  they  appear  to  be  more  frequent  in  cases  of  diarrheal  disturbance, 
and  possibly  have  some  etiological  connection  with  this  condition. 


CHAPTER  IX 
DISEASES  OF  THE  LIVER,  GALL-BLADDER  AND  PANCREAS 

Anatomical  and  physiological  characteristics  of  the  liver  as  compared 
with  those  obtaining  in  adult  life  have  already  been  referred  to  under  the 
Normal  Anatomy  and  Physiology  of  the  Child  (p.  41).  Diseased  states 
of  the  liver,  both  functional  and  organic,  are  on  the  whole  decidedly  less 
frequent  in  early  life  than  later. 

FUNCTIONAL  DISTURBANCE  OF  THE  LIVER 
(Biliousness;  Bilious  Indigestion) 

Of  this  condition ,  to  which  the  old  designations  as  given  above  have  long 
been  applied,  nothing  positive  is  known.  Yet  it  seems  beyond  question 
that,  combined  with  functional  disorders  of  other  portions  of  the  alimen- 
tary apparatus,  the  liver  is  also  involved.  In  some  cases  the  stools  are 
constipated,  or  perhaps  diarrheal,  in  character,  and  of  too  light  a  yellow 
color,  or  even  whitish  showing  the  absence  of  a  normal  amount  of  bile. 
In  how  far  the  various  dyspeptic  sensations  present,  such  as  loss  of  appe- 
tite, nausea,  vomiting,  malaise,  flatulence,  a  bitter  taste  in  the  mouth, 
sallow  tint  of  the  skin,  headache,  and  the  like,  depend  upon  the  liver,  and 
to  what  extent  upon  other  organs,  especially  the  intestine,  it  is  impossible 
to  determine.     The  treatment  is  that  of  intestinal  indigestion. 

CONGESTION  OF  THE  LIVER 

This  may  be  active  or  passive.  The  former  sometimes  occurs  in  acute 
fevers,  from  overeating,  and  from  the  ingestion  of  too  rich  a  diet.  Pass- 
ive congestion  is  more  frequent,  and  is  seen  in  chronic  diseases  of  the 
heart  and  lungs,  chronic  pleurisy,  chronic  malaria,  or  other  causes  which 
interfere  with  the  normal  venous  circulation  in  the  liver  or  in  the  system 
in  general. 

1  Wien.  klin.   Rundschau,  1913,  XXVII,  387. 

2  Ziegler's  Boitriige  f.  path.  Anat.  und  allg.  Path.,  1914,  LVII,  474. 


ICTERUS  833 

The  symptoms  vary  with  the  cause,  and  are  not  characteristic.  The 
liver  increases  in  size,  both  in  an  upward  and  a  downward  direction,  and 
its  hard  edge  may  be  felt  decidedly  below  the  normal  position.  In  the 
acute  condition  there  may  be  pain  and  tenderness  in  the  hepatic  region 
and  perhaps  slight  jaundice;  in  the  chronic  cases  there  may  also  be  moder- 
ate jaundice,  evidences  of  indigestion,  and  the  symptoms  characteristic 
of  the  cause.  When  attendant  upon  cardiac  disease,  a  rapid  diminution 
in  the  enlargement  maj-  follow  improvement  in  the  state  of  the  circula- 
tion. This  diminution  is  of  the  portion  of  the  swelling  which  is  due  to 
an  acute  engorgement.  The  remaining  portion,  dependent  upon  altera- 
tions of  the  hepatic  tissue,  naturally  remains  unchanged.  The  treat- 
ment is  that  of  the  cause. 

ICTERUS 
(Jaundice) 

This  is  a  symptom  due  to  many  causes.  That  designated  icterus 
neonatorum  and  that  due  to  congenital  obliteration  of  the  bile-ducts  have 
already  been  discussed  under  Diseases  of  the  New  Born  (pp.  273,  274), 
where  also  certain  other  conditions  occurring  at  that  period  and  accom- 
panied by  icterus  have  been  referred  to.  There  remain  to  be  considered 
a  number  of  varieties  of  icterus  seen  in  infancy  or  in  childhood. 

The  classification  of  the  forms  of  jaundice,  itself  but  a  symptom,  is  to  an 
extent  unsatisfactory  since  it  is  still  not  thoroughly  understood  how 
the  symptom  is  produced  in  every  case.  Some  investigators  would  group 
most  of  them  together  as  instances  of  infectious  icterus.  Others  denomi- 
nate the  majority  cbstructive,  on  the  ground  that  the  discoloration  is 
caused  by  interference  with  the  passage  of  bile,  the  result  of  a  catarrhal 
swelling  of  the  larger  or  smaller  ducts,  whether  or  not  this  swelling  has  to 
do  with  an  infectious  process.  There  is  a  tendency  also  to  widen  the 
class  of  hemolytic  cases,  in  which  a  hemolysis  within  the  vessels  is  the 
primary  feature.  It  is  certain  only  that  obstruction  is  the  primary  cause 
in  some  instances,  infection  in  others,  and  hemolysis  the  prominent  feature 
in  the  third  group;  but  many  cases  cannot  be  classified  with  accuracy, 
and  may,  too,  belong  to  more  than  one  category.  The  matter  is  so  far 
from  final  settlement  that  an}-  classification  can  be  l)ut  tentative. 

(li  Catarrhal  Icterus  of  Intestinal  Origin 
(Obstructive  Jaundice) 

This  form  of  icterus  is  often  discussed  in  the  class  of  ga'^troenteric 
affections  under  the  title  of  duodenitis  or  gastroduodcnitis.  Its  promi- 
nent symptom,  however,  makes  it  conveniently  considered  with  hepatic 
diseases. 

Etiology.  —The  jaundice  follows  a  gastroduodenal  catarrh,  ami  is 
attributed  to  an  exten.sion  of  the  swelling  of  tlic^  mucous  meml)rane  of 
the  duodenum  to  the  opening  of  the  conunon  bile-duct  or  into  it,  dosing 
it  by  a  catarrhal  inflammation.  To  this  theory  it  has  been  with  reason 
objected  that,  were  the  jaundice  deixMident  upon  catarrhal  swelling,  it 
should  be  much  more  freriuent  in  (>arly  life  than  it  actually  is;  and  it  is 
po.ssiblc  that  the  cause  may  be  of  an  infectious  nature,  in  fact  a  tend- 
ency to  the  epidemic  occurrence  of  this  mild  form  of  icterus  is  sometimes 
seen,  and  allies  this  variety  very  closely  with  that  next  to  be  described. 
The  disease  is  comparatively  infre(iuent  in  children  and  uncommon  in 

53 


834  THE  DISEASES  OF  CHILDREN 

infancy.     I    have   seen    it   in    the   latter    period    in   a   relatively  few 
instances. 

Symptoms. — The  only  characteristic  one  is  the  yellow  coloration 
of  the  skin  and  mucous  membranes  and  of  the  urine.  Before  the  actual 
symptoms  of  jaundice  appear  some  degree  of  indigestion  usually  exists 
for  a  few  days.  This  may  be  so  mild  that  it  is  overlooked,  or  severe 
enough  to  produce  repeated  vomiting,  fever,  abdominal  pain,  and  constipa- 
tion or  sometimes  diarrhea.  A  few  days  later  icterus  develops.  This 
is  usually  slight  at  the  beginning  and  is  first  seen  in  the  conjunctivae,  but 
increases  until  in  a  day  or  two  it  is  well-developed  over  all  the  visible 
mucous  and  cutaneous  surfaces.  It  is  seldom,  however,  of  the  deep 
bronze-j'-ellow  tint  observed  in  some  jaundiced  conditions  in  adults. 
The  appetite  is  diminished  or  normal,  the  tongue  coated,  the  breath 
heavy.  The  urine  is  often  dark-colored  from  bile,  even  before  the  yellow 
tint  of  the  skin  is  apparent.  The  stools  are  more  or  less  acholic,  having 
a  putty  color,  the  degree  of  change  depending  upon  the  completeness 
of  the  obstruction.  Headache,  fretfulness,  and  malaise  are  frequent. 
The  abdomen  is  often  distended  with  gas,  and  there  may  be  tenderness 
in  the  hepatic  region.  '  Itching  of  theskinandslownessof  the  pulse  may 
occur  in  the  severer  cases,  hvtt  are  not  common.  The  liver  is  generally 
slightly  enlarged  and  the  spleen  sometimes  so;  but  an  enlargement  of  this 
latter  suggests  that  the  case  is  not  one  of  simple  catarrhal  jaundice. 

Course  and  Prognosis. — The  prognosis  is  entirely  favorable,  but 
the  course  is  sometimes  somewhat  prolonged,  the  icterus  slowly  fading 
but  not  disappearing  completely  for  2  or  3  weeks.  The  acute  digestive 
symptoms  generally  cease  in  a  few  days  after  the  onset. 

Diagnosis. — This  is  seldom  difficult.  The  association  of  the  con- 
dition with  dyspeptic  disturbances  is  an  indication  of  the  cause,  and  the 
benign  course  and  comparatively  short  duration  remove  doubt.  In 
occasional  cases  in  early  infancy  the  disorder  is  to  be  distinguished  espe- 
cially from  icterus  neonatorum,  septic  icterus,  and  from  such  forms  as 
congenital  family  icterus.  It  is  differentiated  especially  by  the  greater 
degree  of  jaundice  and  the  presence  of  bile  in  large  amount  in  the  urine. 
In  rare  cases  in  early  infancy  obstructive  jaundice  may  occur  from 
malformation  of  the  bile  ducts.  The  course  of  the  case  will  settle  this 
question  in  a  short  time. 

Treatment. — ^This  consists  principally  in  correcting  the  diet.. 
Since  during  jaundice  the  alimentary  tract  finds  much  difficulty  in  the 
digestion  of  fats,  these  should  be  reduced  as  far  as  possible.  The 
starches  too  are  often  a  cause  of  intestinal  indigestion,  and  this  element  of 
the  food  should  be  given  in  somewhat  diminished  amount.  Feeding  with 
skimmed  milk  and  broth  free  from  fat  is  indicated;  1  iter  with  meat,  when 
the  acute  febrile  symptoms  have  disappeared.  Water  should  be  given 
freely,  especially  some  alkahne  water  such  as  Vichy.  Purgatives  every 
day  or  every  other  day  are  of  value,  calomel  being  popular  for  this  purpose, 
but  effective  not  because  it  exerts  any  specific  action  upon  the  liver. 
In  other  cases  the  daily  administration  of  a  saline  laxative  is  of  service, 
such  as  sulphate  of  magnesia  alone  or  combined  with  rhubarb.  The 
employment  daily  or  every  other  day  of  large  enemata  of  tepid  water  is 
an  aid  in  many  cases.  Such  symptoms  as  abdominal  pain,  vomiting  and 
the  like  require  treatment  especially  directed  to  these.  (See  Gastritis,  p. 
721.)  The  administration  of  mineral  acids  has  long  been  popular, 
but  I  have  never  been  able  to  satisfy  myself  that  they  are  of  any  special 
value. 


ICTERUS  835 

(2)  Icterus  of  Infectious  or  Hemolytic  Origin  (see  also  Vol.  II,  p.  489 

Simple  catarrhal  jaundice  shades  almost  imperceptibly  into  the  type 
now  to  be  considered.  This  is  of  wide  variety  and  may  be  made  to  in- 
clude, for  the  sake  of  convenience,  both  those  cases  which  are  clearly 
infectious  in  origin,  and  those  where  it  is  known  that  hemolysis  within 
the  circulation  has  taken  place;  the  latter  condition  being  sometimes 
consecutive  to  the  former;  sometimes  occurring  independently  of  it. 
The  probability  is  that  all,  or  nearly  all,  instances  of  this  form  oif  icterus 
are  in  the  final  event  and  in  the  broader  sense  reall.y  obstructive.  This 
may  be  the  result  in  some  cases  of  choking  of  the  minute  intrahepatic 
blood-vessels  with  released  blood-coloring  matter,  or  of  the  capillary 
bile-ducts  with  thick  bile;  both  resulting  from  the  hemolysis  in  process; 
or  in  other  cases  perhaps  being  caused  by  swelling  of  the  biliary  passages 
(angiocholitis)  the  product  of  the  infectious  process.  Thej'^  are  not 
u.sually,  however,  obstructive  in  the  narrower  sense.  There  is  no  sharp 
differentiation  possible  between  some  of  the  cases  believed  with  reason  to 
be  infectious  and  others  of  the  obstructive  catarrhal  class;  nor  can  we 
make  a  sharp  distinction  between  infectious  and  hemolytic  icterus,  in- 
asmuch as  the  hemolysis  very  probably  in  many  cases  has  an  infectious 
origin.  There  is  also  a  very  close  relationship  between  some  of  the  cases 
of  hemolytic  icterus  and  forms  of  splenomegaly  (Krumbhaar).' 

Etiology. — The  causes  are  various.  The  cases  may  develop  in  the 
course  of  any  of  the  acute  infectious  diseases,  such  as  malaria,  typhoid 
fever,  scarlet  fever,  pneumonia,  and  sepsis.  The  disease  has  also  re- 
peatedly been  known  to  occur  in  local  and  sometimes  widespread  epi- 
demics; a  strong  indication  of  its  infectious  nature.  A  large  number  of 
such  outbreaks  in  England  are  (juoted  by  Guthrie.-  The  veiy  severe 
forms  of  ictei-us  known  as  icterus  gravis  and  as  Weil's  disease  are  also 
clearly  of  an  infectious  nature  in  many  instances.  Pernicious  anemia  is 
likewise  a  cause,  the  icterus  being  the  result  of  the  hemolysis  which  is 
taking  place.  The  nature  of  the  germ  producing  the  infection  is  not 
clearly  understood.  Doubtless  more  than  one  species  have  the  power  to 
cause  it. 

Symptoms.^ — There  is  great  variation  in  the  intensity  of  the  symp- 
toms in  the  different  forms  of  infectious  icterus  which  are  included  under 
this  heading.  In  many  cases  the  discoloration  of  the  skin  is  less  markctl 
than  in  the  catarrhal  icterus  previously  described,  and  the  stools  still 
contain  bile  and  the  urine  none  {acholuric  icterus).  This  is  true  especially 
of  icterus  resulting  from  septic  poisoning.  (See  Sepsis  of  the  New  born,  and 
Pernicious  Anemia,  p.  258,  and  Vol.  II,  p.  462.)  In  other  instances  the 
jaundice  may  be  intense  and  the  urine  exhibit  bile.  The  symjitoms  in 
general  are  little  characteristic,  and  often  overshadowed  i)y  those  of  the 
primary  diseases.  The  amount  of  bile  in  the  urine  varies  with  the  case 
and  with  the  cause.  A  slight  albuminuria  is  not  infrequent.  In  the 
severest  cases  of  infectious  icterus  (Weil's  disease)  there  are  intense  dis- 
coloration of  the  skin,  enlargement  of  the  liver  and  spleen,  high  fever, 
hemorrhage  from  the  mucous  membranes  or  into  the  skin,  ne|)hritis,  (h-- 
lirium,  and  convulsions  or  coma.  In  the  worst  cases  death  may  take 
place  in  the  course  of  a  very  few  days.  Instances  of  this  sort  are  rare  in 
children.     In  some  cases  of  hemolytic  icterus  (Hayeni  Type)-^  there  is  a 

^  Journ.  Kxperim.  Med.,  1912-14,  various  references;  .Vini-r.  .lourii.  Mrd.  Sci..  HU,"), 
CL  227 

■^  Brit.  Jour.  Child.  Dis.,  1!)13,  X,  1. 
3  Presse  m6d.,  1898,  V,  121 


836  THE  DISEASES  OF  CHILDREN 

chronic  icterus  with  bile  in  the  blood-serum  but  not  in  the  urine,  and  no 
symptoms  of  obstructive  jaundice  are  present.  There  is  anemia  and  en- 
largement of  the  liver  and  spleen.  In  none  of  Hayem's  cases  was  there 
an}'  family  history  of  icterus.  The  prognosis,  diagnosis  and  treatment  of 
forms  of  infectious  and  hemolytic  icterus  are  those  of  the  cause.  (See 
also  Vol.  II,  p.  489.) 

(3)  Congenital  and  Familial  Icterus 

(Congenital  Acholuric  Jaundice;  Congenital  Hemolytic  Icterus; 
Congenital  Family  Cholemia) 

Here  might  be  grouped  a  class  of  cases  characterized  by  the  tendency 
to  family  incidence  often  seen,  and  the  very  early  period  at  which  the 
symptoms  appear  in  some  of  them.  Occasionally  infants  are  born 
already  jaundiced,  or  become  so  very  promptly;  have  a  verj^  distinct 
familial  history  of  the  disease;  are  evidently  much  more  ill  than  in  the 
ordinary  cases  of  icterus  neonatorum,  which  has  already  been  discussed, 
and  exhibit  a  discoloration  very  persistent,  although  finally  disappearing. 
I  have  seen  a  number  of  such  cases,  some  with  a  distinctly  hemorrhagic 
tendency.  In  speaking  of  congenital  icterus,  no  reference  is  made  here 
to  the  rare  and  severe  cases  of  jaundice  depending  upon  obliteration  of 
the  bile-ducts  or  congenital  hepatic  cirrhosis,  or  to  the  cases  in  the  new 
born  clearly  the  result  of  sepsis. 

As  to  the  family  incidence,  some  remarkable  examples  have  been 
reported,  as  for  instance  those  of  Pearson^  in  which  10  of  11  children 
born  died  of  jaundice  soon  after  birth;  and  of  Arkwright^  where  14  out  of 
15  children  born  of  one  mother  suffered  jaundice  soon  after  birth,  and 
10  died.  The  mother  had  had  icterus  at  the  age  of  4  years.  A  number  of 
other  series  have  been  pubhshed,  among  them  a  family  reported  by 
Hutchinson  and  Panton^  in  w^hich  the  disease  had  occurred  in  3  genera- 
tions. 

It  is  very  probable  that  cases  of  familial  icterus  may  be  unlike  in 
nature  and  origin.  Minkowsky^  reported  8  cases  occurring  in  the  new  born 
through  3  generations,  and  drew  attention  to  the  fact  that  the  icterus  was 
of  the  acholuric  variety,  the  urine -exhibiting  urobihri  but  no  biliary 
coloring  matter.  This  type  frequently  bears  his  name,  and  the  following 
description  applies  in  large  part  to  it. 

Etiology. — The  nature  of  the  cause  is  not  at  all  understood,  but  it 
seems  probable  that  there  is  a  defect  in  the  blood-forming  functions  of 
the  body,  and  also  that  an  increased  destruction  of  the  corpuscles  takes 
place  in  the  spleen.  The  influence  of  heredity  has  already  been  spoken  of. 
Other  diseases  seem  to  pki}'  no  part.  In  older  children  chilling  or  over- 
fatigue has  seemed  in  some  cases  to  be  the  immediate  cause. 

Symptoms. — The  symptoms  may  be  present  at  birth  or  appear 
soon  after  it;  or  in  another  class  of  familial  cases  develop  only  after  the 
patient  reaches  childhood  or  even  adult  life.  The  degree  of  jaundice 
varies  with  the  case,  and  even  in  the  same  individual  from  time  to  time. 
It  is  usually  not  great,  and  sometimes  is  very  slight  and  is  of  an  acholuric 
character,  the  urine,  although  dark-colored  from  ui'obilin,  being  free  of 
biliary  coloring  matter,  or  showing  only  at  times  a  small  amount,  and 
the  feces  containing  bile.     As  pointed  out  by  Chauffard'^  there  is  increased 

1  Underwood's  Diseases  of  Children,  1846,  1G8. 

2  Edin.  Med.  Jour.,  1902,  LIV,  156. 

••'  (^uirt.  .Jour,  of  Mod.,  1909,  II,  432. 

'  Verhandl.  der.  Kong.  f.  inn.  Med.,  1900,  XVIII,  316. 

5  La  sem.  m6d.,  1907,  XXVII,  25. 


ICTERUS  837 

fragility  of  the  corpuscles  to  salt  solutions  in  this  congenital  hemolj-tic 
jaundice,  one  of  the  normal  strength  producing  separation  of  the  blood- 
coloring  matter.  This  fragihty  is  in  sharp  contrast  to  the  condition 
found  in  ordinary  obstructive  jaundice,  in  which  there  is  an  increased 
resistance  of  the  red  blood-corpuscles  to  salt  solution.  Bile-pigment  is 
generally  present  in  the  blood-serum.  The  spleen  is  always  enlarged. 
There  is  anemia  of  moderate  degree,  with  a  few  megaloblasts  and  normo- 
blasts and  many  reticulated  red  cells,  reaching  even  as  high  as  20  per 
cent,  of  the  erythrocj'tes.  The  number  of  leucocytes  is  not  altered. 
There  is  sometimes  seen  a  tendency  to  hemorrhage,  but  not  to  the  extent 
characteristic  of  the  primary  hemorrhagic  diseases.  As  the  patient 
grows  older  the  general  health  may  be  but  little  affected,  except  perhaps 
during  the  exacerbations.  There  are  no  digestive  disturbances,  and  no 
abdominal  tenderness  or  pain. 

Course  and  Prognosis. — The  prognosis  is  uncertain.  In  early 
infancy  many  die  soon ;  but  should  this  not  happen  the  later  course  seems 
to  be  without  influence  upon  the  general  health.  The  jaundice,  however, 
never  entirely  disappears. 

Diagnosis. — This  rests  especially  upon  the  family  history,  when 
obtainable ;  the  moderate  degree  of  jaundice;  the  fragihty  of  the  corpuscles; 
the  beginning  in  infancy  usually  seen;  the  absence  of  bile  from  the  urine 
and  its  presence  in  the  feces;  and  the  enlargement  of  the  spleen.  Biliary 
cirrhosis  of  the  liver  is  of  later  development,  generally  without  familial 
history,  and  there  is  a  greater  degree  of  jaundice.  Banti's  disease  (Vol.  II, 
p.  486)  is  primarily  a  disorder  of  the  spleen,  the  jaundice  being  generally 
a  later  development,  and  no  increased  fragility  of  the  corpuscles  being 
present. 

Treatment. — For  most  of  the  cases  this  is  symptomatic  merely. 
Splenectomy  has  been  done  with  success,  bur  should  not  be  employed 
unless  the  general  condition  of  the  patient  is  suffering. 

(4)  Icterus  from  Other  Causes 

Jaundice  appears  in  many  other  conditions  than  those  mentioned.  In 
some  it  is  but  a  mild  symptom;  in  some,  although  a  prominent  one,  it  is 
grouped  with  other  features  in  such  a  way  that  a  separate  description 
of  the  complex  is  necessary.  Typical  obstructive  jaundice,  not  of  a 
catarrhal  nature,  occurs  in  childhood  rarely  from  the  presence  of  impacted 
gall-stones,  the  pressure  of  a  nuilignant  growth  ui)()n  the  bile  ducts,  or  the 
wandering  of  a  worm  into  these.  The  ingestion  of  such  jioisons  as  arsenic 
and  phosphorus  or  the  accident  of  a  snake  bite  are  possible  causes  of 
icterus  of  a  hemolytic  nature.  Cirrhosis  of  the  liver  may  have  icterus  as 
a  symptom,  or  it  may  occur  in  the  course  of  hepatic  abscess,  or  of  some  form 
of  splenic  enlargement  or  of  anemia,  and  is  very  well  marked  in  acute 
yellow  atrophy,  and  in  the  acute  infectious  hemoglobinemia  already 
described  (\).  2()2)  among  diseases  of  the  new  born. 

(5)  Acute  Yellow  Atrophy  of  the  Liver 

This  disease,  one  of  the  forms  of  icterus  gravis,  uncommon  at  any  time 
of  life,  is  very  rare  in  childhood  and  infancy.  Phillips'  wjis  able  to  collect 
41  cases  in  children,  including  1  of  his  own;  and  Francioni-  places  the 
number  at  40,  and  to  these  perhaps  half  a  dozen  more  might  be  added. 
One  of  the  youngest  of  the  series  was  in  an  infant  of  4  days  (Polit/er).^ 

'  .\inor.  Joiirn.  Med.  Sci.,  I'.MJ.  CXI.Ill,  177. 

2  Riv.  (Uclin.  pcdi.-it..  I'M  t,  XII,  053. 

3  Jahrl).  f.  Kindorli.,  ISCO.  Ill,  40. 


838  THE  DISEASES  OF  CHILDREN 

Twice  as  many  boys  as  girls  are  attacked;  in  contradistinction  to  adult 
life,  in  which  more  women  suffer,  I  have  seen  2  cases  in  later  childhood, 
one  of  which,  in  a  boy  of  7  j^ears,  I  have  previously  reported.^ 

The  usual  pathological  lesions  are  found  at  autopsy;  the  liver  being 
shrunken  perhaps  to  half  its  size,  with  a  more  or  less  wide-spread  paren- 
chymatous degeneration  present.  Efforts  at  a  reparative  process  in 
the  liver  have  been  discovered.  The  causes  and  symptoms  are  exactly 
as  in  adult  life.  The  former  are  entirely  unknown,  although  the  occurrence 
of  acute  digestive  disturbances,  acute  febrile  diseases,  and  syphilis  have 
sometimes  been  in  existence,  and  may  have  predisposed  in  some  way. 
The  disease  is  ushered  in  by  icterus  of  an  ordinary  type,  which  may  last 
a  few  days  or  1  or  2  weeks.  After  this  there  develops  rapidly  high  fever, 
hemorrhages,  vomiting,  and  such  nervous  symptoms  as  convulsions,  deli- 
rium, or  coma  as  in  other  forms  of  severe  icterus.  In  addition  there  is  a 
progressive  diminution  in  the  size  of  the  liver  with  local  tenderness,  and 
death  takes  place  in  3  or  4  days.  The  diagnosis  rests  upon  the  grave  general 
symptoms,  the  presence  of  intense  jaundice,  the  diminution  in  the  size  of 
the  liver,  and  the  occurrence  of  bile  and  of  leucin  and  tyrosin  in  the  urine. 
It  is  difficult  to  understand  how  patients  with  the  serious  alterations  of  the 
liver,  which  this  disease  shows  at  autopsy,  could  survive,  and  an  element 
of  doubt  must  attach  to  the  few  reported  instances  of  recovery,  although 
some  appearing  to  be  reasonably  certain  instances  are  on  record.  Fletcher- 
reports  a  case  recovering  after  repeated  hypodermoclysis. 

There  are  certain  cases  described  as  subacute  atrophy.  Chisholm^ 
details  9  cases  which  he  had  collected  from  medical  literature,  Wegerle'* 
2  cases,  and  Fraser^  1  case.  The  causes  are  probably  different  from  that 
of  the  acute  disease,  varying  with  the  case,  and  sometimes  are  distinctly 
discoverable  at  autopsy;  cirrhosis,  tuberculosis,  and  infection  being  among 
them.  The  symptom  always  present  was  jaundice;  but  in  other  respects 
the  clinical  manifestations  were  not  characteristic.  Leucin  and  tyrosin 
were  not  found  in  the  urine  in  any.  The  disease  lasted  several  weeks. 
All  of  the  cases  reported  have  terminated  fatally. 

ENLARGEMENT  OF  THE  LIVER 

Increase  of  the  size  of  the  liver  is  very  frequent  in  early  life,  being  a 
symptom  in  a  large  number  of  diseased  conditions.  Among  these  may 
be  mentioned  rachitis;  congenital  syphilis;  tuberculosis;  congestion,  espe- 
cially from  heart  disease;  fatty  and  amyloid  degeneration;  tumors; 
hydatid  cysts;  cirrhosis;  and  certain  diseases  of  the  blood  and  the  blood- 
making  organs.  The  diagnosis  of  these  various  conditions  is  made  by 
consideration  of  the  symptoms  exhibited  by  other  organs.  The  disorders 
now  to  be  described  have  hepatic  enlargement  as  a  symptom  at  some 
period  of  their  course. 

CIRRHOSIS  OF  THE  LIVER 

This  is  an  uncommon  disease  in  early  life.  I  recall  seeing  but  2  cases, 
one  an  instance  of  typical  alcoholic  cin-hosis  in  a  girl  of  11  years;  the 
other  a  probable  bihary  cirrhosis  in  a  child  of  6  years.     Collective  studies 

1  Arch,  of  Ped.,  1899,  XVI,  330. 

2  Garrod,  Batten  and  Thursfield,  Diseases  of  Children,  1913,  210. 

3  Brit.  Jour.  Child.  Dis.,  1914,  XI,  397. 

'  Frankfurter  Zeit.  f.  Pathol.,  1914,  XV,  89. 
5  Amer.  Joum.  Med.  Sci.,  1916,  CLII,  202. 


'  ENLARGEMENT  OF  THE  LIVER  839 

of  the  affection  as  observed  in  children  have  been  made  by  Howard,^ 
Edwards,-  Jones^  and  others. 

Etiology. — The  disease  may  attack  children  of  any  age,  but  appears 
commonest  in  later  childhood.  Jones  records  cirrhosis  33  times  in 
17,891  autopsies  on  children,  giving  an  incidence  of  0.185  per  cent.  In 
Edwards'  series  of  100  cases  65  were  from  6  to  16  years  old.  The  majority 
of  the  reported  instances  have  been  in  males  (Edwards,  53  males;  33 
females ;  14  not  stated) .  The  causes  are  various,  but  are  probably  of tenest 
of  a  toxic  or  infectious  nature.  The  disease  appears  in  some  instances 
to  follow  the  acute  infectious  fevers,  but  the  real  influence  of  these  is 
doubtful.  According  to  most  statistics  the  misuse  of  alcohol  has  been 
the  cause  in  a  not  large  percentage  in  early  hfe.  Thus  in  Edwards' 
series  of  100  cases  there  was  a  positive  history  of  the  ingestion  of  alcohol 
in  only  11.  In  Jones'  collection  of  300  cases,  however,  representing  differ- 
ent types  of  cirrhosis,  but  not  including  the  cases  of  Ghose,^  there  were 
74  instances  of  alcohohc  cirrhosis.  Syphilis  appears  to  be  the  causative 
factor  in  few  instances;  and  although  it  is  probable  that  the  majority 
of  those  seen  in  early  infancy  depend  upon  a  syphihtic  process,  it  is  very 
likely  that  in  most  of  those  designated  as  cirrhosis  the  pathological  lesions 
are  not  purely  of  a  cirrhotic  nature.  Malaria  and  tuberculosis  are  also 
probable  causes,  and  chronic  passive  congestion  from  disease  of  the  heart, 
polyserositis,  or  other  agents  gives  rise  to  the  disorder.  The  occurrence 
of  a  congenital  bilary  cirrhosis  has  already  been  referred  to  in  connection 
with  congenital  obliteration  of  the  bile  ducts  (p.  273).  This  is  the  form 
of  cirrhosis  oftenest  seen  in  the  new  born,  but  is  rare.  Bihary  cirrhosis 
is  met  with  more  frequently  in  later  childhood  than  before  this  period. 
A  famihal  tendency  has  also  been  observed  in  cirrhosis  of  both  the  portal 
and  biliary  types.  An  interesting  family  historj'  with  4  children  affected 
is  reported  by  Bramwell.^ 

Not  included  in  the  statistics  quoted  appears  to  be  a  special  iorni  of 
biliary  cirrhosis  reported  as  not  infrequent  in  infants  in  hot  countries, 
which  exhibits  a  decided  familial  tendency.  This  is  stated  by  Ghose 
to  be  very  common  in  India,  where  he  has  observed  400  cases,  of  which 
only  6  recovered. 

Pathological  Anatomy. — This  is  entirely  of  the  nature  seen  in 
adult  life,  with  the  exception  that  shrinking  of  the  size  of  the  organ  at 
this  period  is  less  frequent.  This  is  probably  because  the  cause  is  less 
often  the  misuse  of  alcohol,  and  the  process  is,  therefore,  not  so  often  in 
children  an  atrophic  or  portal  cirrhosis,  as  that  of  the  hypertrophic  or 
biliary  form.  In  the  cases  of  portal  origin  there  is,  namely,  generally  a 
diminution  in  the  size  of  the  liver,  its  surface  is  uneven,  and  section 
shows  an  irregular  distribution  of  connective-tissue-hypertrophy  com- 
pressing and  penetrating  the  lobules,  and  producing  degeneration  and 
atrophy  of  the  cells.  In  the  biliary  type,  or  hypertrophic  cirrhosis 
(Hanot's  cirrhosis),  the  spleen  and  hver  arc  enlarged,  the  latter  being 
greenish  or  yellowish  in  color,  and  on  section  showing  an  interlobular 
overgrowth  of  connective  tissue  compressing  the  small  bile-ducts,  and  an 
inflammation  of  these.  In  another  type  of  hypertrophic  cirrhosis,  depend- 
ing upon  the  chronic  passive  congestion  of  cardiac  disease,   especially 

1  .\mer.  Jour.  Med.  Sci.,  1887,  XCIV,  350. 

2  .\rch.  of  Ped.,  1890,  VII,  502. 

'  Brit.  Jour.  Child.  Di.s.,  1907,  IV,  1. 

*  Lancet,  1895,  I,  321. 

&  Kdin.  Med.  Journ.,  1910,  XVII,  90. 


840  THE  DISEASES  OF  CHILDREN 

chronic  pericarditis,  the  )uU-meg  liver  is  produced.  To  the  evidences  of  en- 
gorgement in  this  form  is  added  a  moderate  development  of  fibrosis  under 
the  capsule  and  unevenly  throughout  the  liver.     The  spleen  is  enlarged. 

Although  this  description  represents  the  types  of  pathological 
changes  seen,  mixed  forms  are  common,  the  cirrhotic  changes  occurring 
often  irregularly.  The  pathological  alterations  observed  in  the  liver 
in  hereditary  syphilis  may  be  clearly  cirrhotic,  showing  an  interstitial 
hepatitis,  and  this  may  be  further  combined  with  scattered  gummata 
of  various  size.     (See  Syphilis  of  the  Liver,  pp.  565,  573,  577.) 

Symptoms. — These  do  not  differ  greatly  from  those  seen  in  adult 
hfe.  The  early  symptoms  are  modified,  ])ut  point  to  a  digestive  dis- 
turbance, with  loss  of  appetite  and  not  infrequently  diarrhea  and  occa- 
sional vomiting,  followed  later  by  progressive  emaciation  with  a  sallow 
pallor,  more  or  less  dilatation  of  the  abdominal  veins,  enlargement 
of  the  liver  and  spleen,  and  ascites.  Albumin  may  appear  in  the  urine 
if  a  complicating  nephritis  develops.  Later,  the  liver  may  grow  smaller 
than  normal  [atrophic  form),  or  it  may  remain  enlarged  (hijpertrophic 
form).  Hemorrhages  from  the  skin  or  mucous  membranes  are  un- 
common, and  the  temperature  is  irregular;  there  being  sometimes  attacks 
of  fever  with  abdominal  pain  and  sometimes  a  subnormal  temperature. 
In  the  atrophic  form  of  the  disease  jaundice  is  absent  or  shght  and  ascites 
is  common ;  while  in  biliary  cirrhosis  the  icterus  is  often  intense,  the  urine 
contains  bile,  the  stools  are  not  acholic,  the  spleen  is  greatly  enlarged, 
and  ascites  is  less  frequent.  The  symptoms  of  congenital  biliary  cirrhosis 
have  already  been  described  (p.  273). 

Course  and  Prognosis.- — The  course  is  often  more  rapid  than  in 
adults,  although  the  disease  sometimes  lasts  several  years.  The  prog- 
nosis is  unfavorable,  death  taking  place  from  exhaustion,  often  with  diar- 
rhea and  sometimes  with  delirium,  coma,  or  convulsions.  Pulmonary 
complications  may  develop  and  be  the  direct  cause  of  the  fatal  ending. 
In  cases  of  cirrhosis  of  any  type  of  long  duration  the  growth  of  the  body 
may  be  retarded.  In  the  hypertrophic  form  exacerbations  of  symptoms 
occur  from  time  to  time,  with  renewed  fever  and  pain,  followed  by  periods 
of  quiescence. 

Diagnosis. — Early  in  the  disease  there  are  no  certain  data  upon 
which  a  diagnosis  can  be  based;  later,'cnlargement  of  the  liver  and  spleen, 
jaundice,  and  attacks  of  fever  and  abdominal  pain,  make  the  diagnosis  of 
biliary  cirrhosis  probable.  Banti^s  disease  (see  Vol.  II,  p.  486)  is  dis- 
tinguished by  the  leucopenia,  the  lesser  degree  of  jaundice  and  the  pre- 
dominating and  early  splenic  enlargement.  Congenital  hemolytic  icterus 
is  recognized  by  the  absence  of  bile  from  the  urine,  the  much  less  de- 
gree or  absence  of  enlargement  of  the  liver,  and  the  increased  fragility 
of  the  red  blood  corpuscles.  The  presence  of  ascites  is  oftener  dependent 
upon  a  tuberculous  peritonitis:  and  it  is  only  if  the  liquid  is  removed 
by  tapping  that  an  abnormal  diminution  in  the  size  of  the  liver  may  be 
determined  and  the  diagnosis  of  an  atrophic  cirrhosis  made,  or  a  hyper- 
trophic cirrhosis  found  associated  with  chronic  pericarditis  or  medias- 
tinitis.  The  occurrence  of  hemorrhages  is  a  suggestive  symptom  of 
cirrhosis. 

Treatment. — This  can  be  but  palliative,  with  the  intent  of  pro- 
longing life.  The  diet  should  be  as  unirritating  as  possible,  milk  being 
most  useful  for  this  purpose.  Should  there  be  any  suspicion  of  the  ex- 
istence of  syphilis,  treatment  for  this  disease  should   be  given.     This  is 


AMYLOID  LIVER  841 

the  only  form  of  cirrhosis  in  which  permanent  benefit  by  drugs  may  be 
hoped  for.  On  the  ground  that  the  S3'mptoms  may  be  due  to  congestion 
and  not  to  cirrhosis,  purgatives  should  be  tried;  and  if  disease  of  the  heart 
is  present,  remedies  should  be  given  appropriate  to  this.  As  in  the  case  of 
adults,  aspiration  of  the  fluid  is  sometimes  necessary.  Surgical  meas- 
ures to  establish  collateral  circulation  have  repeatedly  succeeded  in 
adults,  and  recovery  followed  in  the  case  of  a  boy  of  6  years  with  alcoholic 
cirrhosis  reported  by  Grosz.^ 

FATTY  LIVER 

Fatty  infiltration  of  the  hver  is  a  common  affection  in  early  life, 
especially  in  infancy.  Freeman^  found  it  in  40  per  cent,  of  496  autop- 
sies in  children;  and  his  studies  show,  too,  that  there  was  no  special 
relationship  of  this  lesion  to  any  one  other  disorder,  although  it  was 
oftener  present  in  acute  infections  than  in  chronic  wasting  diseases.  The 
liver  is  large,  smooth,  and  in  w^ell-marked  cases  of  a  decidedly  j'ellow  color, 
and  is  distinctly  greasy  on  section.  Wollstein^  found  fatty  liver  in  a 
surprisingly  large  number  of  cases  dying  of  tuberculous  diseases  (45  in  67 
cases).  In  fatty  infiltration,  which  is  the  common  form,  the  hepatic  cells 
are  infiltrated  with  fat,  but  the  cell-nucleus  is  unaltered.  When  fatty 
degeneration  is  present,  the  result  of  toxic  or  infectious  processes,  the 
cells  and  nuclei  undergo  a  degenerative  process,  and  become  granular 
and  cease  to  stain  normally.  Apart  from  the  enlargement  there  are  no 
special  symptoms  of  fatty  infiltration  which  make  it  possible  to  recognize 
it  with  certainty  during  life. 

The  prognosis  and  treatment  are  that  of  the  disorder  producing  it,  as 
far  as  this  can  be  ascertained. 

AMYLOID  LIVER 

Amyloid  degeneration  of  the  liver  is  the  result  of  a  number  of  con- 
ditions, and  is  associated  with  similar  degeneration  in  other  organs,  such 
as  the  kidneys,  spleen  and  intestine.  Chronic  suppurative  processes  are 
prominent  among  the  causes.  Consequently,  amyloid  liver  is  seen  in 
tuberculous  disease  of  the  bones  and  lymphatic  glands,  and  in  long-con- 
tinued empyema  and  bronchiectasis.  It  may  occur  also  as  a  result  of 
syphilis  and  rickets.  The  increase  in  the  size  of  the  liver  is  often  greater 
than  in  any  other  form  of  hepatic  enlargement.  The  organ  is  smooth, 
waxy  and  glistening  in  appearance,  hard,  firm,  and  gives  the  onhnary 
amyloid-red  reaction  with  iodin(\  The  walls  of  the  arterioles  first  sufl'er 
from  the  degeneration  and  then  the  hepatic  cells. 

The  symptoms  are  indefinite  and  are  largely  those  of  the  causative 
primary  disorder.  There  is  a  very  striking  waxy  pallor  of  tiie  face, 
emaciation  is  common,  diarrhea  is  frequent,  and  the  iligestion  in  general 
much  impaired.  Alljumiiiuria  and  general  tht)psy  are  not  unconnnon, 
depending  upon  the  comi)licatiiig  amyloid  involvement  of  the  kidiicysVr 
upon  pressure  of  the  very  large  liver  ujion  the  abdominal  vessels.  Un- 
less produced  by  such  causes,  ascites  is  infreciuent.  There  is  generally 
no  icterus,  abdominal  pain  or  tenderni'ss.  Tlie  much  enlarged,  sinodlh 
liver  and  spleen  can  Ije  readily  felt  through  the  abdominal  walls. 

The  course  of  the  disease  is  slow,  and  the  prognosis  is  unfavorable, 
although  not  invariably  so  if  the  causative  disease  can  be  iirrested. 
Death  occurs  from  exhaustion  or  from  some  intercurrent  afTection. 

1  Rcf.  M(.ti:its8clir.  f.  KiiKl.'ihcilk.,  1!»0;},  II,  38G. 

2  Arch,  of  Fed.,   1<»()().  XVII,  SI. 

3  Aincr.  Jour.  Med.  Sci,.  I'.tlVJ,  CXXIII,  S17. 


842  THE  DISEASES  OF  CHILDREN 

The  diagnosis  is  based  upon  the  occurrence  of  very  large  Uver  and 
spleen,  the  pecuKarly  waxy  pallor,  and  the  presence  of  some  primary 
affection  capable  of  producing  the  degeneration.  Treatment  is  purely 
that  of  the  cause. 

ABSCESS  OF  THE  LIVER 
(Suppurative  Hepatitis) 

This  is  a  very  uncommon  condition  in  early  life.  The  disease  at  this 
period  has  been  studied  especially  by  Musser^  in  1890,  who  could  collect 
but  34  cases;  and  more  recently  by  Legrand^  who  has  increased  the  number 
to  122.  Even  in  tropical  countries  the  latter  writer  found  abscess  un- 
common in  early  life. 

Etiology. — The  causes  are  the  same  as  in  adults,  among  them  being 
trauma;  suppurative  processes  of  the  bones,  appendix,  peritoneum,  etc.; 
the  infectious  diseases;  dysentery;  and  pulmonary  tuberculosis.  In 
addition,  in  infancy,  abscess  is  due  to  the  wandering  of  ascarides  into  the 
bile-ducts,  and  exceptionally  is  dependent  upon  sepsis  connected  with 
the  umbihcal  vessels.  In  Legrand's  series  31  per  cent,  of  the  cases 
depended  upon  dysentery;  19  per  cent,  on  trauma;  15  per  cent,  on  ap- 
pendicitis; 6  per  cent,  on  typhoid  fever;  10  per  cent,  on  tuberculosis;  13 
per  cent,  on  intestinal  worms  and  9  per  cent,  on  pyemia.  The  abscess 
may  be  single,  as  when  resulting  from  trauma;  or  oftener  multiple,  as 
when  of  septic  origin,  the  immediate  cause  then  being  a  suppurative 
pylephlebitis.  Occasionally  pus  from  a  heptic  abscess  collects  between 
the  diaphragm  and  the  liver  {subphrenic  abscess).  It  is  to  be  noted, 
however,  that  abscess  in  this  region  may  arise  in  other  ways. 

Symptoms. — The  symptoms  of  solitary  abscess  consist  of  pain  and 
tenderness  in  the  hepatic  region;  enlargement  of  the  liver  either  upward  or 
downward ;  fever  of  a  hectic  type  with  chills  and  sweats ;  emaciation ;  loss 
of  strength;  vomiting;  diarrhea;  loss  of  appetite;  leucocytosis,  and  some- 
times slight  jaundice.  In  some  instances  the  pain  is  not  in  the  region 
of  the  hver  but  in  the  chest,the  right  shoulder,  or  the  abdomen.  There 
may  be  painful  respiration,  and  cough  or  shortness  of  breath  if  the  disease 
is  in  the  upper  portion  of  the  liver.  When  the  sj'^mptoms  described  are 
associated  with  a  history  of  an  injury  in  the  hepatic  region,  occurring  per- 
haps some  time  before,  the  presence  of  abscess  is  very  probable.  Only  a 
successful  aspiration  can  make  the  diagnosis  certain.  The  symptoms  of 
multiple  abscess  are  less  definite.  If,  following  the  existence  of  a  known 
suppurating  focus,  there  develop  painful  enlargement  of  the  liver,  jaun- 
dice, fever  of  a  hectic  type,  diarrhea,  and  typhoid  sjonptoms,  the  exist- 
ence of  multiple  abscesses  may  be  suspected. 

Course  and  Prognosis. — -These  vary  with  the  nature  of  the  affec- 
tion. The  duration  is  generally  from  1  to  2  months.  If  in  the  case  of 
single  abscess  the  pus  can  be  reached  by  operation,  the  chance  of  recovery 
is  fair,  depending,  however,  upon  the  seat.  When  in  the  upper  portion 
close  to  the  diaphragm  the  prognosis  is  not  favorable.  Multiple  abscesses 
always  give  a  most  unfavorable  prognosis  Treatment  is  entirely  sur- 
gical, aspiration  or  incision  being  required. 

MORBID  GROWTHS  OF  THE  LIVER 

Tumors  of  the  liver  are  not  of  common  occurrence  in  early  life.  They 
have  been  studied  especially  by  Steffen^  who  collected  39  cases  of  primary 

1  Cyclop.  Dis.  of  Child.,  Keating;  1890,  III,  466. 

2  Arch,  de  m6d.  des  enf.,  1906,  IX,  129. 

^  Malign.  Geschwiilste  im  Kindersalter,  1905,  77. 


DISEASES  OF  THE  GALL-BLADDER  AXD  BILE-DUCTS  843 

malignant  growths.  Carcinoma,  adenocarcinoma,  and  sarcoma  may  be 
mentioned  among  neoplasms  of  this  class.  In  the  majority  of  cases  the 
tumor  is  secondary  to  one  elsewhere  in  the  body,  but  in  a  considerable 
number  it  is  primary.  It  is  noteworthy  that  in  early  life  carcinoma  ap- 
pears to  be  more  frequent  in  the  liver  than  in  other  localities.  P  have 
observed  1  case  of  primary  carcinoma  in  an  infant  of  21  months,  and 
have  been  able  to  collect  in  all,  including  this,  55  instances  of  primary 
carcinoma  of  the  Hver  in  early  life.  Among  nonmahgnant  growths  are 
congenital  multiple  cysts,  Upoma,  fibroma,  adenoma  and  angioma. 
Either  of  the  last  two  may  be  multiple  or  single.  Veedei-  and  Austin^ 
describe  a  case  of  multiple  congenital  hemangio-endothelioma,  and  refer 
to  3  others  recorded  in  medical  literature. 

The  symptoms  of  growths  of  the  liver  consist  in  steadily  increasing 
size  of  the  organ,  which  often  exhibits  irregularly  nodular  masses-  in- 
creasing debiUty;  abdominal  pain;  and  the  various  symptoms  depending 
upon  pressure.  Yet  ascites  and  icterus  may  be  absent  until,  perhaps, 
the  latest  stages. 

Among  new  growths  may  conveniently  be  placed  tuberculosis  of  the 
liver,  alwaj^s  secondary  to  tuberculous  lesions  elsewhere.  Only  occasion- 
ally large,  cheesy  masses  are  found,  but  mihary  tubercles  on  the  surface 
of  the  liver  or  scattered  through  the  organ  are  of  common  occurrence. 

ECHINOCOCCUS  OF  THE  LIVER 
(Hydatids) 

This  is  of  very  exceptional  occurrence  in  infants  and  children,  and  this 
is  especiallj^  true  of  North  America.  The  causes  and  symptoms  are  the 
same  as  in  adult  life.  The  parasite  is  the  echinococcus-form  of  the  taenia 
echinococcus,  a  minute  tapeworm  occurring  in  the  dog.  If  by  the 
ingestion  of  contaminated  food  or  water  the  eggs  by  chance  enter  the 
stomach  of  man  or  other  animals,  they  produce  embryos  which  penetrate 
the  blood-vessels  and  lymph-channels  and  lodge  oftenest  in  the  hver. 
Here  the  parasite  develops  into  a  cyst,  which  increases  in  size  inde- 
pendently of  the  production  of  daughter-cysts.  The  principal  symptom 
is  the  enlargement  of  the  hepatic  area  which  the  cysts  produce.  This 
may  be  discovered  by  percussion  and  palpation,  the  latter  sometimes 
giving  a  sensation  of  fluctuation  and  a  "hydatid  fremitus."  Aspiration 
reveals  a  clear  fluid  in  which  the  booklets  of  the  i)arasite  are  found. 
Other  symptoms  of  various  sorts  maj'  develop,  depentling  upon  pros- 
sure  in  different  directions;  and  in  this  case  are  similar  to  tiie  pressure- 
symptoms  which  may  be  produced  bj^  hepatic  growths  of  any  nature. 
Occasionally  rupture  of  the  cyst  may  occur,  or  sometimes  suppuration 
take  place  in  it  and  produce  evidences  of  sepsis.  Tiie  prognosis  is 
always  doul)tfui.  Spontaneous  recovery  may  take  place  through  simple 
shrinking  of  the  cyst,  or  through  external  rupture  and  iliscluirge;  but 
this  is  rare.  Oftener  death  occurs  unless  treatment  is  instituted.  This 
latter  is  entirely  surgical  in  nature. 

DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS 

Conditions  of  this  nature  are  very  rare  in  early  hfc.  ( \)ngenital  oblit- 
eration of  the  bile-ducts  has  already  been  described.  (Seep.  273.)  Only 
exceptionally  there  exists  a  congenital  absence  of  the  gall-bladder.     Sev- 

»  Amer.  Jour.  Med.  Sci.,  1918,  CLV,  79. 

«  Amer.  Jour.  Mod.  Sci.,  1912,  CXLIII,  lOJ. 


844  THE  DISEASES  OF  CHILDREN 

eral  sucli  reported  cases  have  been  collected  l)y  Eshner.^  Occasionally 
a  round  worm  penetrates  into  the  bile-duct  and  sets  up  an  inflanimation 
there.  Acute  cholangitis  and  cholecystitis  are  very  infrequent  con- 
ditions, but  may  occur  after  typhoid  fever  or  from  sepsis.  Cholecystitis 
of  a  more  chronic  nature  is  probably  not  an  infrequent  sequel  of  typhoid 
fever.  Tuberculosis  of  the  gall-bladder  is  sometimes  seen,  and  that  of 
the  bile-ducts  is  not  uncommon,  producing  small  nodules  or  cavities 
within  the  liver.  Very  exceptionally  gall-stones  are  discovered.  Thom- 
son- collected  6  reports  of  gall-stones  in  the  new  born  and  added  another. 
Still''  found  in  medical  literature  20  cases  of  gall-stones  in  early  life,  to 
which  he  added  3  of  his  own.  In  all  of  these  the  stones  were  found  in 
the  feces,  or  in  the  gall-bladder  at  autopsy;  10  were  in  infants  still-born  or 
dying  in  a  few  weeks;  4  in  those  from  3  to  9  months  of  age;  1  in  an 
"infant";  8  were  in  children  from  3  to  14  years  old.  Khautz"*  could 
collect  but  15  cases  from  medical  literature,  6  of  these  being  in  infants. 

DISEASES  OF  THE  PANCREAS 

Organic  disease  of  this  organ  plays  a  very  minor  role  in  early  life. 
Syphilitic  involvement  with  the  production  of  gummata  and  increase  of 
the  connective  tissue  and  atrophy  of  the  glandular  substance  is  occasion- 
ally seen.  Tuberculous  nodules  of  considerable  size,  or  an  infiltration 
by  many  small  nodules,  may  accompany  a  general  tuberculosis  of  the 
body  of  the  patient,  and  is  not  at  all  infrequent.  Amjdoid  degeneration 
may  occur  in  conjunction  with  this  change  in  other  organs.  Tumors 
also  may  involve  the  pancreas,  being  either  primary,  or  secondary  to 
morbid  growths  elsewhere.  Among  the  former  primary  sarcoma  has 
been  described  by  Litten''  and  others.  Cysts  are  occasionally  found, 
oftenest  of  the  class  of  retention  cysts.  Calculi  and  ascarides  have  been 
reported  present  in  the  pancreatic  duct.  An  acute  pancreatitis  is  occa- 
sionally seen  as  one  of  the  manifestations  of  mumps.  (See  p.  500.) 
Even  this  is  infrequent;  and  dependent  upon  other  causes  pancreatitis 
is  of  great  rarity,  but  may  occur  in  the  course  of  infectious  diseases;  as  a 
result  of  the  presence  of  round  worms  in  the  duct;  by  infection  extending 
from  the  intestine;  or  be  metastatic 4n  origin.  The  inflammation  may 
be  either  hemorrhagic  or  suppurative.  Although  abdominal  pain  and 
tenderness  rapidly  followed  by  collapse  occur  as  symptoms,  these  are 
not  sufficiently  clistinctive  to  allow  of  an  diagnosis  being  made.  A 
chronic  pancreatitis  is  distinctly  more  common,  producing  a  fibrosis  of  the 
organ.  The  most  frequent  cause  is  hereditary  syphilis,  although  the 
disease  may  also  accompany  gastroenteritis.  It  is  seen  also  in  diabetes 
mellitus.  It  is  possil)le  that  some  of  the  cases  of  fatty  stools  depend  upon 
this  form  of  pancreatitis. 

How  often  a  functional  disturbance  of  the  pancreas  may  account  for 
difficulty  in  digestion  is  not  known,  but  it  is  very  probable  that  some  of 
the  instances  of  f  at-indigest  ion  may  be  due  to  this.  Some  cases  of  infantil- 
ism are  associated  with  disturbance  of  the  functions  of  the  pancreas. 
(See  Infantilism,  Vol.  II,  p.  .533.) 

1  Med.  News,  1894,  LXIV,  548. 

2  Edinb.  Hosp.  Rop.,  1898,  V,  1. 

3  Transac.  Path.  Soc.  London,  1899,  I,  151. 

4  Centralbl.  f.  d.  CJrcnzgeb.  der  Med.  u.  Chir.,  1913,  XVI,  545. 

5  Deut.  med.  Wochenschr.,  1888,  XIV,  901. 


ACUTE  PERITONITIS  845 

CHAPTER  X 

DISEASES  OF  THE  PERITONEUM 
ACUTE  PERITONITIS 

In  the  great  majority  of  cases,  peritonitis  is  secondary  to  a  lesion  else- 
where in  the  body.  An  acute  primar}-  peritonitis  does,  however,  some- 
times occui ,  although  much  less  frequenth'  than  the  secondary  form. 

Etiology. — Age  exerts  a  decided  influence.  The  disease  may  occur 
before  birth  as  a  result  of  hereditary  syphilis.  In  the  new  born  perito- 
nitis is  not  uncommon,  depending  upon  septic  infection  usually  from  the 
umbilicus.  In  infants  after  this  period  it  is  rare,  and  becomes  frequent 
again  onh'  with  the  increasing  incidence  of  appendicitis.  This  latter 
condition  is  much  the  most  common  cause  of  a  secondary  peritonitis  in 
childhood,  the  inflammation  either  following  a  perforation  or  resulting 
from    extension    of   the   process   from   the   perityphlitic   inflammation. 

Very  rarely  in  early  life  perforation  of  a  gastric  or  duodenal  ulcer, 
or  the  rupture  of  an  abscess  in  some  other  abdominal  organ,  gives  rise  to 
secondary  peritonitis.  I  have  seen  it,  for  instance,  consecutive  to  per- 
foration of  a  duodenal  ulcer  in  a  child  of  5  months;  in  another  of  19 
months  to  a  diverticulitis;  and  in  a  considerable  number  of  instances 
under  my  observation  it  has  followed  intestinal  perforation  in  typhoid 
fever.  In  other  cases  peritonitis  may  be  produced  by  the  rupture  of  an 
empyema,  or  of  an  abscess  resulting  from  spinal  caries  or  from  inflamma- 
tion about  the  kidney.  Strangulation  of  the  intestine,  as  in  hernia  and 
intussusception,  may  likewise  cause  the  disease,  as  may  also  forms  of 
enteritis.  Inflammation  of  the  female  genital  tract  is  an  occasional  cause, 
although  with  so  much  less  frequency  than  in  adult  life  that  it  is  entirely 
exceptional.  Trauma,  such  as  blows  received  on,  or  operation  done  upon, 
the  abdomen,  and  exceptionally  exposure  to  cold,  are  sometimes  followed 
by  a  primary  peritonitis.  Acute  infectious  diseases  may  produce  a  peri- 
tonitis dependent  upon  the  infection.  Here  especially  are  to  be  mentioned 
erysipelas,  grippe,  scarlet  fever,  typhoid  fever,  and  diphtheria;  while 
pleurisy  and  pneumonia  may  have  peritonitis  in  their  train. 

p]very  case  of  acute  peritonitis  is  directly  dependent  upon  the  action 
of  some  species  of  microorganism,  either  aloneor  often  in  conibinalion  with 
other  species.  The  streptococcus  is  the  most  freciuent  cause  in  cases 
depending  upon  sepsis  in  the  new  born,  or  in  those  following  scarlet 
fever,  tonsillitis,  erysipelas  and  some  other  infectious  diseases.  In  some 
instances  a  streptococcic  peritonitis  appears  to  be  primary.  The 
pneumococcus  is  capabU^  of  i)r()(hicing  a  |)rimary  peritonitis  or  may  b(>  the 
agent  in  cases  consecutive  to  j)neuni()nia  or  pleurisy.  This  pneuniococ- 
cic  peritonitis  is  more  frequent  in  early  than  in  adult  life.  Barling' 
collected  234  reported  ca.'^es  occurring  in  children.  Of  these  (>2  were 
males  and  172  females.  The  infection  is  probably  oftenest  through 
the  blood-channels,  although  Annand  and  liowen-  wouUlTassign  the  ma- 
jority of  cases  to  infection  from  the  intestinal  tract.  In  perhaps  the 
greater  number  of  instances  of  peritonitis  tiie  bacillus  coli  is  f  jund  present, 
very  frefjuently  in  comi)ination  with  some  other  species.  Other  ca.ses 
exhibit  the  staj^hylococcus  aureus,  the  l)acillus  pyocyaneus,  the  proteiis 
vulgaris,  or  other  germs.  The  gonococcus  is  the  cause  of  ptMitonitis 
oftenest  in  cases  following  vulvovaginitis. 

'  PniclitioiKM,  l<»r2.  L.W.W  111,  .'):{7. 
=  Lancet,  1 '.•()«•),  I,  1.")<>1. 


846  THE  DISEASES  OF  CHILDREN 

Pathological  Anatomy .^ — The  lesions  are  not  different  from  those 
seen  in  adult  life.  There  is  at  first  redness  and  dullness  of  the  peri- 
toneum followed  by  exudation  of  fibrinous  and  purulent  serum.  In  some 
instances  the  fibrinous  element  predominates;  in  others  the  serous  or 
the  purulent.  In  the  first,  patches  of  yellowish  lymph  are  found  upon 
the  abdominal  wall  and  upon  the  peritoneum  covering  the  intestines, 
uniting  these  latter  together  more  or  less  firmly  according  to  the  duration 
of  the  case.  In  those  recovering  firm  adhesions  may  remain.  In  cases 
where  the  serous  element  predominates  there  is  a  considerable  effusion 
of  yellowish,  clear  or  slightly  cloudy,  serous  fluid  in  addition  to  the  plastic 
lymph.  Purulent  peritonitis  is  the  form  always  present  in  perforative 
cases,  and  often  without  this  accident  is  a  later  stage  of  acute  peritonitis 
from  whatever  cause.  In  this  form  there  are  either  collections  of  pus 
usuallj^  localized  in  small  pockets  formed  by  loops  of  intestine  bound 
together  by  adhesions ;  or  in  a  smaller  number  of  cases  mostly  free  in  the 
abdominal  cavity  and  produced  in  large  amount.  The  pus  has  sometimes 
a  most  offensive  odor,  especially  in  perforative  cases.  In  those  dependent 
upon  the  pneumococcus  it  is  of  a  greenish-j^ellow  color  and  without  offen- 
sive odor.  In  streptococcic  peritonitis  the  secretion  is  yellowish  or 
greyish  and  thin,  and  shows  little  tendency  to  encapsulation. 

In  all  varieties  of  the  disease  the  lesions  may  be  general,  or  limited 
to  certain  regions  as,  for  instance,  the  pelvis,  the  appendix,  or  the 
neighborhood  of  some  intestinal  lesion  elsewhere.  In  localized  purulent 
peritonitis  an  abscess  of  some  size  may  result,  walled  off  by  inflammatory 
products  from  the  rest  of  the  peritoneal  cavity.  In  fetal  peritonitis 
fibrous  adhesions  may  remain  constricting  the  intestines  or  perhaps 
obhterating  the  bile-duct. 

Symptoms. — The  symptoms  of  general  peritonitis  in  typical  cases 
in  childhood  do  not  differ  materially  from  those  seen  in  adult  life.  The 
onset  is  usually  sudden  and  severe,  characterized  by  vomiting,  high  fever 
of  103°  to  105°F.  (39.4°  to  40.6°C.),  abdominal  pain  and  tenderness,  consti- 
pation, or  very  frequent^  diarrhea.  In  a  short  time  the  child  presents 
the  appearance  of  being  very  ill.  The  face  has  a  pallid,  strained,  sunken 
aspect,  with  sharpness  and  coldness  of  the  nose,  hollowness  about  the 
eyes  and  dryness  of  the  teeth  and  tongue.  The  expression  is  clearly  that 
of  pain.  The  pulse  is  rapid,  small  and  compressible,  and  the  breathing  is 
shallow  and  rapid  on  account  of  the  pain  which  abdominal  respiration 
produces.  The  temperature  continues  high,  but  may  be  normal  or 
subnormal.  The  abdomen  is  rigid,  tympanitic  and  even  meteoric.  The 
patient  lies  on  his  back  with  the  legs  drawn  up  on  the  abdomen;  the 
extremities  are  often  cold  and  cyanotic;  the  mind  is  clear;  vomiting  may 
cease  or  may  continue  troublesome;  hiccough  may  be  present.  The  urine 
is  often  scanty,  or  there  may  be  dysuria  necessitating  the  employment  of 
the  catheter.  The  blood  generally  exhibits  a  decided  leucocytosis, 
especially  in  the  perforative  cases,  except  in  the  very  severe  instances 
where  no  reaction  can  take  place,  and  where  even  a  leucopenia  may  be 
found.  Later  in  the  disease,  if  the  course  is  not  too  short,  evidences  of 
fluid  in  the  abdominal  cavity  may  appear,  shown  by  dullness  in  the  flanks 
and  by  fluctuation.     This  symptom  is,  however,  often  absent. 

In  localized  peritonitis  the  severity  and  the  character  of  the  symptoms 
depend  largely  upon  the  cause.  The  most  frequent  form  is  that  associ- 
ated with  appendicitis  and  has  already  been  described  (p.  803).  Its 
presence  is  also  to  be  suspected  whenever  a  child  with  gonorrheal  vulvo- 
vaginitis suddenly  develops  fever  with  abdominal  pain,  tenderness  and 


ACUTE  PERITONITIS 


847 


distention.  I  have,  however,  seen  this  in  but  2  instances.  Rarelj'  in 
children  the  inflammation  is  locaUzed  just  below  the  diaphragm  {sub- 
phrenic abscess).  This  is  usually  secondary  to  affections  of  the  liver  or 
often  to  pneumonia  or  pleurisy,  and  the  symptoms  simulate  closely  those 
of  empyema.     (See  p.  851.) 

Acute  peritonitis  in  infancy  may  exhibit  symptoms  far  from'character- 
istic,  and  often  so  obscure  that  no  diagnosis  is  made  during  hf  e.  Vomiting 
may  be  absent  and  the  temperature  httle 
elevated  if  at  all.  On  the  other  hand,  it 
may  be  high,  especially  in  the  new  born. 
The  abdomen  is  distended  and  rigid;  but 
distention  of  and  pain  in  the  abdomen  in 
infancy  are  so  common  from  other  causes, 
such  as  colic,  that  the  symptom  is  of  little 
value.  Abdominal  tenderness  is  character- 
istic when  present,  but  is  often  absent. 
In  many  cases,  however,  the  symptoms 
are  sufficiently  hke  those  of  childhood  to 
make  the  diagnosis  clear. 

Course  and  Prognosis. — The  disease 
is  always  a  serious  one  with  uncertain 
outcome,  the  course  and  final  issue  depend- 
ing largely  upon  the  localization,  the 
nature  of  the  pathological  lesions,  and,  to 
some  extent,  on  the  specific  cause.  In 
the  most  severe  cases  of  widespread  general 
purulent  peritonitis  the  course  is  short 
and  death  is  hable  to  occur  in  3  or  4 
days  or  even  less.  Other  cases  not  so 
intense  in  character  last  a  longer  time, 
terminating  fatally  in  1  to  2  weeks. 
General  peritonitis  dependent  upon  in- 
testinal perforation  is  always  of  a  serious 
type  and  runs  a  rapid  and  fatal  course; 
unless  perhaps  checked  by  prompt 
operative  interference.  The  earlier  opera- 
tion is  done  in  these  cases  the  greater  the 

chance  of  recovery.  Peritonitis  of  the  j^^y  Laparotomy  July  21.  Post- 
new  born,   like  any  other  septic   variet}^  is     mortem  examination  showed  thick 

nearly  always  fatal.  Fibrinous  peritonitis  plastic  exudate.  A  diplococcus, 
gives  a  better  prognosis  than  the  purulent    streptococcus   and    an    undeter- 

V  ,  If,  ,  -11  r  mmed  bacillus  were  found  in  the 

form  and  serous  cases  are  still  more  lavor-    fl^ij 
able.     But  general  peritonitis  is,  as  a  rule, 

a  very  fatal  malady,  with  death-rate  of  probably  60  to  80  percent. 
In  localized  peritonitis  tiio  prognosis  is  much  better  in  proportion  as 
the  area  involved  is  small,  depending,  too,  largely  on  the  nature  of  the 
lesion.  A  small  fibrinous  area  following  upon  inflannnation  of  some 
neighboring  region  disappears  with  the  recovery  of  the  original  lesion. 
There  is  always  a  danger,  however,  that  the  localized  inllainmation  may 
become  a  general  one.  Purulent  peritonitis  may  be  entirely  localized 
and  may  then  end  in  recovery  by  discharging  into  the  rectum,  the  kidneys, 
or  through  the  umbilicus.  The  cavity  remaining  gradually  fills  witli 
granulation  tissue,  and  heals  as  does  any  other  absce.s.s  cavity.     The 


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P'iG.  273. — Skptic  Pkuitoxitis. 
John  W.  Entered  the  Chil- 
dren's Hospital  of  Philadelphia, 
July  15,  aged  4  days.  Increasing 
weakness,  distended  ai)d()men, 
moderate,  irregular  temperature, 
chiefly     subfebrile    until    the   las^t 


848 


THE  DISEASES  OF  CHILDREN 


danger  of  extension  to  the  general  peritoneal  cavity  is  greater  in  a  local- 
ized purulent  peritonitis  than  in  the  fibrinous  form.  The  course  is  often 
considerably  prolonged,  the  temperature  remaining  elevated,  and  often 
exhibiting  a  distinctly  hectic  tj^pe.  Examination  of  the  abdomen  may 
reveal  the  presence  of  an  abscess. 

The  nature  of  the  germ  exerts  an  influence  upon  the  course  and  prog- 
nosis. Streptococcic  peritonitis  is  the  variety  oftenest  seen  in  sepsis  in  the 
new  Ijorn  (Fig.  273) ;  after  some  of  the  infectious  fevers,  as  scarlet  fever  and 
diphtheria;  and  in  some  of  the  cases  of  peritoneal  infection  from  the 


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Fig.  274. — Pxeumococcic  Perito.mtis;  J'ollowed  by  Phlebiti.s  and  Empyema. 
MarKarot  K.,  aged  5  years.  Sudden  onset  Dec.  1  of  apparently  acute  gastric  indiges- 
tion, with  vomiting,  diarrhea  and  fever.  Seemed  convalescing  in  less  than  a  week;  Dec. 
6,  developed  severe  abdominal  pain,  fever,  and  diarrhea;  by  Dec.  17,  symptoms  had 
moderated,  but  physical  signs  of  fluid  in  lower  part  of  abdominal  cavity  had  appeared. 
Signs  of  pleuropneumonia  developed,  and  child  much  more  ill.  Abdominal  condition 
grew  worse.  Operation  for  peritonitis  done  Dec.  23.  l}^  quarts  (1420)  pus  removed, 
containing  pneumococci.  Gradual  improvement.  Pulmonary  signs  cleared  up.  Dec.  29, 
phlebitis  left  leg,  with  fever;  .Jan.  7,  empyema  has  developed,  operated  upon  today; 
Jan.  16,  convalescing.  Chart  shows  very  moderate  fever  even  shortly  before  peritoneal 
cavity  opened. 


intestinal  tract.  The  course  is  severe  and  rapid  to  a  fatal  termination. 
Pneumococcic  peritonitis  (Fig.  274)  is  oftenest  preceded  or  attended  by 
some  affection  of  the  lung  or  pleura,  but  may  develop  independently 
of  this  as  a  primary  disorder.  It  often  presents  certain  definite  character- 
istics. After  the  sudden  onset  and  early  severe  symptoms  a  remission 
may  take  place  in  from  6  to  8  days,  but  diarrhea  and  abdominal  disten- 
tion persist  and  the  case  often  suggests  typhoid  fever.  In  the  course  of 
about  2  weeks  fluid  collects  in  the  alidominal  cavity.     The  general  symp- 


ACUTE  PERITONITIS  849 

toms  ma}-  remain  favorable,  or  there  may  be  emaciation  and  fever  and  a 
condition  suggesting  tuberculous  peritonitis.  The  pus  produced  in  this 
form  shows  a  decided  tendency  to  encapsulation,  usually  in  the  lower  part 
of  the  abdomen  or  about  the  umbilicus,  and  after  several  weeks  may  be 
discharged  in  some  direction,  if  not  earlier  evacuated  by  operative  inter- 
ference. In  many  instances,  however,  the  inflammation  finally  becomes 
widespread;  or  the  course  may  be  very  short  from  the  beginning,  no 
remission  occurs,  the  inflammation  becomes  general,  and  the  prognosis  is 
unfavorable,  the  worst  cases  dying  in  a  few  days  from  the  onset.  The 
mortality  in  the  pneumococcic  cases  is  much  less  than  in  those  dependent 
upon  the  streptococcus.  Annand  and  Bowen^  in  91  collected  cases  in 
children,  omitting  2  in  which  the  result  was  unknown,  found  a  total 
mortality  of  51.66  per  cent.  In  62  of  the  cases  operation  was  performed; 
in  29  not.  The  mortality  in  87  cases  collected  by  Koos^  was  39.55 
per  cent. 

Gonococcic  peritonitis  develops  oftenest  by  an  extension  from  a 
vulvo-vaginitis.  It  may  be  general  in  nature,  but  usually,  although 
the  onset  may  be  threatening,  the  symptoms  soon  abate,  the  in- 
flammation is  locahzed  in  the  pelvic  region,  and,  as  a  rule,  resolution 
occurs.  When  gonococcic  peritonitis  is  general  the  course,  prognosis 
and  termination  are  the  same  as  in  other  severe  forms;  but  this  variety 
fortunately  is  rare. 

Complications. — Peritonitis  is  oftener  a  sequel  to  other  conditions 
than  itself  a  primary  disease.  In  many  instances,  however,  there  is 
shown  a  tendency  for  inflammation  of  other  serous  membranes  to  develop 
simultaneously  with  it,  such  as  pleurisy,  meningitis,  or  pericarditis. 
This  is  especially  so  in  infancy,  and  when  the  disease  depends  upon  a 
general  septic  poisoning  with  the  streptococcus,  or  sometimes  upon  the 
pneumococcus. 

Diagnosis. — In  typical  cases  this  presents  little  difficult}^  and 
rests  upon  the  sudden  onset;  pecuUar  expression  of  the  face;  obstinate 
initial  or  continued  vomiting;  prostration  and  collapse;  abdominal  tender- 
ness and  distention;  and  later  the  discovery  of  a  general  or  localized 
collection  of  fluid.  As,  however,  the  disease  is  subject  to  many  variations 
the  diagnosis  is  often  difficult.  Typhoid  fever  with  abdominal  pain  and 
distention  often  resembles  it  closely.  The  matter  of  greatest  importance 
is  to  recognize  the  occurrence  of  perforation  and  consequent  peritonitis 
in  this  disease.  This  is  often  exceedingly  difficult,  especially  in  children. 
The  occurrence  of  sudden  fall  of  temperature  followed  by  a  rise;  the 
sudden  onset  or  increase  of  abdominal  pain,  tenderness,  rigidity  and  dis- 
tention; and  the  marked  increase  in  the  severity  of  the  symptoms  with 
acceleration  of  pulse  and  respiration  point  strongly  to  the  development  of 
peritonitis.  I  havi;  repeatedly  seen  cases,  however,  where  none  of  these 
symptoms  were  sufficiently  characteristic  to  warrant  a  diagnosis  early 
enough  to  be  of  service  to  the  patient.  The  ai)sence  of  leucocytosis  may 
be  of  value  in  excluding  peritonitis,  but  is  not  trustworthy.  Intussus- 
ception or  other  obstruction  of  the  bowel  is  to  be  borne  in  mind  when 
making  a  diagnosis.  Like  peritonitis,  it  may  cause  vomiting,  tympanites 
and  constipation.  The  last  is,  however,  more  obstinate  in  intestinal 
obstruction,  and,  as  intussusception  is  nearly  always  the  variety  of  ol)- 
struction  seen  in  children,  the  passage  of  bl<KKly  mucus  with  straining, 

^  Loc.  cit. 

»  Archiv  f.  liinderh.,  1907,  XLVI,  228. 


850  THE  DISEASES  OF  CHILDREN 

and  the  discovery  of  a  tumor,  aid  in  its  recognition.  Acute  ileocolitis 
may  strongly  suggest  localized  peritonitis  due  to  an  appendicular  in- 
flammation; and  when  peritonitis  develops  as  a  sequel  to  acute  enteritis 
it  may  be  with  difficulty  differentiated  from  the  primary  disease.  Pneu- 
monia and  pleurisy,  with  their  well-recognized  tendency  in  some  cases  to 
develop  pain  referred  to  the  abdomen,  may  readily  simulate  peritonitis. 
There  is,  however,  no  real  abdominal  tenderness  in  these  conditions,  and 
a  careful  examination  of  the  thorax  will  generally  serve  to  make  the  diag- 
nosis certain.  (SeeAppendicularPneumonia, Vol.II,p.80.)  Pneumococcic 
peritonitis,  when  in  the  stage  of  effusion,  is  to  be  distinguished  from  fuher- 
cidous  peritonitis  by  the  more  sudden  and  severe  onset.  It  is  to  be  differ- 
entiated from  appendicitis  bj'-  the  absence  or  slight  development  of 
localized  rigidity  in  the  appendicular  region.  Peritonitis  in  infancy  may 
exhibit  typical  symptoms,  but  when  not  can  hardly  be  recognized  with 
certainty  during  hfe. 

Treatment. — The  medical  treatment  of  acute  general  purulent 
peritonitis  is  unsatisfactory  and  at  the  most  palliative  and  symptomatic. 
The  best  procedure  is  very  prompt  exploratory  operation  to  discover 
the  cause  of  the  inflammation  and  to  allow  a  discharge  of  the  pus  from 
the  abdominal  cavity.  In  less  severe  cases,  and  where  it  is  doubtful 
whether  pus  is  present,  and  in  any  case  where  operation  cannot  for  any 
reason  be  performed,  other  measures  must  be  employed.  The  patient 
should  be  at  absolute  rest  and  the  peristalsis  and  pain  held  in  control  by 
opiates,  best  given  hypodermically.  The  early  employment  of  free 
purgation  by  salines  with  the  intent  of  favoring  elimination  is  recom- 
mended by  many,  but  condemned  by  others  on  the  ground  that  it  dis- 
turbs the  resting  of  the  intestines  which  is  so  greatly  to  be  desired.  It 
would  certainly  seem  safer  to  employ  frequent,  large,  normal  saline  ene- 
mata  to  attain  this  end.  Owing  to  the  obstinate  early  vomiting  it  is  often 
inadvisable  to  administer  any  food  by  the  mouth  at  first,  nutritive 
enemata  and  water  being  given  by  the  bowel.  If  water  is  not  retained 
hypodermoclysis  may  be  employed  to  supply  liquid  to  the  system. 
Lavage  of  the  stomach  may  be  useful  for  the  same  purpose  and  to  control 
vomiting.  Later  broth,  peptonized  skimmed  milk,  and  albumen-water 
may  be  allowed  in  small  amounts  frequently  repeated.  The  application 
of  ice-bags  to  the  abdomen  is  to  be  recommended,  or,  if  this  fails  to  relieve 
the  pain,  warm  compresses  or  turpentine  stupes  may  be  employed.  For 
the  prostration  strychnine,  camphor,  or  adrenaline  may  Vje  given  hypoder- 
mically. 

In  cases  of  localized  peritonitis,  the  need  of  prompt  surgical  aid  is 
not  always  so  great,  depending  largely  upon  the  cause.  When  secondary 
to  appendicitis,  although  not  certainly  purulent,  undoubtedly  the  safest 
procedure  is  early  operation.  When  the  peritonitis  is  gonorrheal,  opera- 
tion is  rarely  indicated  and  the  medical  treatment  prescribed  is  to  be 
preferred.  In  any  case  of  localized  peritonitis  where  an  accumulation  of 
pus  can  be  discovered,  operation  should  be  done,  since  trusting  to  spon- 
taneous evacuation  is  an  unsafe  procedure.  Whenever  peritonitis  can  be 
determined  to  be  pneumococcic  in  nature,  the  waiting  for  encapsulation 
or  local  manifestation  is  usually  to  be  advised.  It  is  always  to  be 
borne  in  mind  that  the  large  majority  of  cases  of  peritonitis,  except  in 
infancy,  are  dependent  upon  appendicitis  and  that  the  operative  treat- 
ment as  recommended  for  this  is  always  to  be  preferred,  unless  it  is  cer- 
tain that  appendicitis  is  not  the  cause.     (See  Appendicitis,  p.  800.) 


NON-TUBERCULOUS  CHRONIC  PERITONITIS  851 

Subphrenic  Abscess 

This  may  be  regarded  as  a  localized  purulent  peritonitis,  the  peri- 
toneum having  been  involved  secondarily  to  some  neighboring  suppurative 
process.  It  is  uncommon  in  children.  Jopson^  could  find  but  22  cases 
under  15  years  of  age  in  a  total  of  247  reported  in  medical  literature. 
It  maj^  be  due  to  pneumonia,  empj^ema,  abscess  of  the  liver,  tuberculous 
cavities,  or  appendicular  abscess.  The  most  frequent  situation  is  above 
the  liver;  much  less  commonly  above  the  spleen.  The  symptoms  are 
almost  identical  with  those  of  empyema,  and  the  diagnosis  is  hardly 
possible  except  after  operative  interference,  done  generally  with  the 
idea  that  empyema  is  present.  Occasionally  the  abscess  contains  air 
also,  and  then  simulates  a  pyo-pneumothorax.  The  treatment  is  that 
for  empyema. 

NON-TUBERCULOUS  CHRONIC  PERITONITIS 

The  lesions  and  symptoms  of  this  condition  vary  with  the  cause.  A 
chronic,  localized  purulent  peritonitis  may  follow  the  acute  form,  and 
it  may  be  long  before  the  abscess  heals.  In  other  cases  there  is  a  diffuse 
fibrinous  inflammation,  sometimes  chronic  from  the  beginning,  with 
extensive  adhesions.  This  may  be  localized  especially  about  the  spleen 
or  the  liver,  or  may  involve  the  coils  of  the  intestines,  and  the  fibrous 
bands  produced  may  result  in  intestinal  obstruction.  The  disease  is 
usually  recognized  only  at  autops3\  Fetal  peritonitis  has  become  of  the 
chronic  variety  by  the  time  of  birth  and  numerous  firm  fibrous  adhesions 
may  be  found  post-mortem. 

Chronic  Ascitic  Peritonitis. — This  is  a  somewhat  characteristic  form 
of  chronic  peritonitis  so  closely  resembling  the  tuberculous  variety  that 
many  claim  it  is  identical.  Henoch^  and  others,  however,  maintain  its 
independence.  The  condition  is  certainly  an  uncommon  one,  seen 
generally  in  later  childhood,  and  the  cause  is  unknown,  although  trauma 
may  have  an  influence,  and  cases  have  been  reportetl  after  measles.  In 
this  variety  there  is,  in  addition  to  a  fibrinous  inflammation  with  ad- 
hesions ill  smaller  or  larger  degree,  a  large  amount  of  serous  cff"usion. 
The  symptoms  resemble  those  of  tuberculous  peritonitis  in  the  gradual 
failure  of  health,  loss  of  appetite,  weakness,  and  abdominal  distention 
with  evidences  of  fluid  free  in  the  peritonitic  cavity.  They  differ  from 
them,  however,  in  the  absence  of  nodular  masses  discoverable  on  pal- 
pation, the  moderate  degree  or  even  lack  of  abdominal  tenderness,  the 
normal  or  but  slightly  elevated  temperature,  and  the  absence  of  that 
degree  of  emaciation  and  constitutional  involvement  usually  seen  in  the 
tuberculous  variety.  In  fact  the  chief  symptom  is  ascites  for  which  no 
discoveral)le  cause  can  be  found.  If  no  tuberculin  reaction  isobtainabl(>, 
and  if  inoculation  of  guinea-pigs  with  tiie  fluid  procured  by  aspiration 
gives  a  negative  result,  the  disease  is  probably  not  tuberculosis.  The 
disorder  is  to  be  distinguished  from  simple  ascites  through  the  failure  of 
any  evidence  of  disease  of  the  liver,  kidneys  or  heart.  The  coursi-  and 
prognosis  are  usually  favorable,  the  fluitl  lieing  gradually  absorbed.  In 
some  cases  chronic  peritonitis  may  be  combined  with  a  chronic  pleurisy 
with  serous  effusion,  mediastinitis,  or  a  serous  pericarditis,  the  condition 
then  i)eing  in  fact  a  polyserositis  of  a  non-tul)ercul()Us  variety. 

1  Arch,  of  Ped.,  1904,  XXI,  120. 
*  VorlesuriK.  u.  Kitulcrk.,  l.Si)."),  o42. 


852  THE  DISEASES  OF  CHILDREN 

Treatment  consists  in  rest,  the  administration  of  diuretics  and  of 
saline  purgatives  in  moderate  amount,  the  maintaining  of  the  general 
health  by  tonic  measures,  and  eventually  aspiration  or  even  laparotomy 
if  recovery  does  not  take  place  without  these. 

TUBERCULOUS  PERITONITIS 

The  great  majority  of  the  cases  of  chronic  peritonitis  are  of  this 
nature,  but  the  disease  may  also  develop  acutely  as  a  part  of  mihary 
tuberculosis.  Respecting  the  frequency  of  its  occurrence,  Schmitz^ 
found  24  cases  in  9134  sick  children  examined;  i.e.  0.26  per  cent.,  and 
Casaell-  18  cases  in  15,000  children;  i.e.  0.12  per  cent.  It  would  appear 
to  be  a  distinctly  less  common  disease  in  this  country  than  in  Europe. 

These  statistics  apply  to  tuberculous  peritonitis  in  its  clinical  mani- 
festations. From  a  purely  pathological  point  of  view  it  is  a  frequent 
form  of  tuberculosis,  especially  in  early  life.  Thus  Biedert^  in  883 
collected  post-mortem  examinations  on  tuberculous  children  found  in- 
volvement of  the  peritoneum  to  some  extent  in  162;  i.e.  18.3  per  cent, 
but  many  of  these  consisted  of  no  more  than  the  occurrence  of  scattered 
tubercles  upon  the  serous  membrane.  In  fact  peritonitis  of  mild  degree 
is  often  only  a  post-mortem  discovery,  the  clinical  symptoms  having  been 
those  of  tuberculosis  elsewhere  in  the  body. 

Etiology. — In  the  study  of  cases  with  clinical  manifestations,  the 
influence  of  age  is  prominent  among  the  predisposing  causes.  According 
to  the  statistics  of  Osier'*  in  357  collected  cases  at  all  ages  10  were  under 
10  years  of  age;  75  from  10  to  20  years;  and  adults  as  frequently  attacked 
as  children.  Many  observers,  however,  consider  the  disease  rather  one 
of  early  life.  Relative  to  the  distribution  throughout  infancy  and  child- 
hood, tuberculous  peritonitis  is  uncommon  in  the  1st  year,  Weil  and 
Pehu^  having  been  able  to  find  only  100  cases  with  chnical  manifestations 
occurring  in  the  nursing  period.  Rarely,  however,  the  disease  may  be 
even  congenital  (Charrin).^  In  306  cases  reported  by  Faludi^  nearly  half 
were  between  the  ages  of  3  and  7  years,  only  8  being  under  1  year;  while 
of  161  cases  studied  by  Fletcher^  84  (52.17  per  cent.)  were  from  1  to  5 
years  old. 

The  disease  is  about  equally  divided  between  the  sexes  (156  boys; 
150  girls,  Faludi).  Exceptionally  the  development  of  tuberculosis  of 
the  peritoneum  may  appear  to  be  incited  by  such  causes  as  trauma  of 
the  abdomen;  or  the  occurrence  of  some  infectious  disease  may  exert 
an  influence,  as  with  other  forms  of  tuberculosis.  In  the  great  majority 
of  cases  no  such  cause  can  be  discovered.  In  these  the  process  may 
develop  apparently  simultaneously  in  the  peritoneum  and  elsewhere  in 
the  body,  as  in  the  pleura;  or  may  be  secondary  to  lesions  in  the  lungs, 
the  intestine,  or  the  mesenteric  or  other  lymphatic  glands,  or  bones; 
or  be  one  of  the  evidences  of  a  general  miliary  tuberculosis.  Oftenest, 
from  a  purely  clinical  standpoint,  tuberculous  pei'itonitis  seems  to  be  the 
primary  or  sole  manifestation  of  tuberculosis,  and  probably  in  some 
instances  it  is  in  fact  so;  but  certainly  much  more  frcxiuently  it  is  sec- 

1  Jahrb.  f.  Knderheilk.,  1897,  XLIV,  316. 

2  Deut.  med.  Wochenschr.,  1900,  XXVI,  596. 

3  Jahrb.  f.  Kinderheilk.,  1884,  XXI,  158. 

*  Johns  Hopkins  Hosp.  Rep.,  1891,  II,  67. 
■-  Archiv  de  med.  des  enf.,  1909,  XII,  415. 

6  Lyon  med.,  1873,  XIII,  295. 

7  Jahrb.  f.  ffinderheilk.,  1905,  LXII,  304. 

*  Garrod,  Batten  and  Thursfield,  Diseases  of  Children,  1913,' 242. 


TUBERCULOUS  PERITONITIS  853 

ondary  to  some  small  or  perhaps  undiscovered  remote  tuberculous  lesion. 
The  question  of  the  type  of  tubercle  bacillus  oftenest  present  in  the 
different  manifestations  of  tuberculosis  has  been  considered  elsewhere. 
(See  p.  542.)  Tuberculous  peritonitis  is  probably  one  of  the  most  fre- 
quent varieties  dependent  upon  the  bovine  bacillus.  Concerning  the 
method  of  invasion,  tubercle  bacilU  may  reach  the  peritoneum  either 
through  the  general  circulation,  as  in  cases  of  widespread  acute  tuber- 
culosis; from  the  intestinal  tract  by  way  of  the  Ijmiphatic  vessels  and 
the  mesenteric  glands,  with  or  without  a  discoverable  primary  intestinal 
lesion;  or,  still  oftener,  from  other  regions  of  the  body.  Indeed  the 
combination  of  tuberculous  peritonitis  with  intestinal  tuberculosis  is 
often  absent.  In  Borschke's^  226  cases  of  tuberculous  peritonitis  86 
had  the  intestine  intact. 

Pathological  Anatomy. — -Examination  made  after  laparotomy  or 
autopsy  in  fatal  cases  of  acute  miliary  tuberculosis  shows  a  dissemination 
of  grey  miUary  tubercles  over  the  involved  portion  of  the  peritoneum. 
These  tubercles  may  disappear,  if  the  case  recovers,  or  may  increase  in  size 
and  become  more  or  less  confluent  into  larger  masses,  which  maj^  show 
caseous  degeneration  in  the  central  parts.  The  serous  membrane  is 
congested,  thickened,  and  exhibits  more  or  less  fibrinous  exudation,  while 
a  certain  amount  of  serous,  seropurulent,  or  even  hemorrhagic  effusion 
is  always  present,  although  the  last  is  infrequent  in  children.  The 
omentum  is  usuall}^  much  involved  and  may  be  greatly  thickened  with 
large  tuberculous  nodules,  or  shrunken,  or  rolled  up  into  a  firm  mass. 
The  relative  amount  of  the  fibrinous  and  of  the  fluid  exudate  varies  with 
the  subject.  When  the  former  predominates  and  there  is  very  little  fluid 
the  coils  of  the  intestines  are  firmly  bound  together  and  to  the  abdominal 
wall  and  the  various  viscera  by  dense  adhesions.  In  these  cases  the 
condition  is  analogous  to  that  seen  in  fibroid  phthisis.  In  other  instances 
the  fluid  is  in  large  amount,  either  free  in  the  peritoneal  cavity  or  en- 
capsulated when  of  longer  duration,  and  there  is  only  a  moderate 
amount  of  fibrin  on  the  serous  membrane,  and  some  scattered  and  easily 
torn  adhesions  are  present.  Many  cases  show  the  development  of  both 
conditions  in  various  degrees,  and  in  either  form  the  process  may  go  on  to 
recovery,  more  or  less  trace  of  peritonitic  inflammation  perhaps  remaining 
permanently^  with  encapsulation  of  any  caseous  masses  which  have  been 
produced.  In  still  other  cases  the  large  tuberculous  caseous  masses 
which  have  developed,  especially  in  the  fibrous  form,  finally  produce 
pus,  which  discharges  itself  through  the  abdominal  wall  especiallj'  at 
the  navel,  or  by  ulceration  into  the  intestine. 

Symptoms. — Based  upon  the  complex  of  symptoms  and  upon  the 
anatomical  lesions  various  classifications  of  tuberculous  peritonitis  have 
been  made.  Neither  symptoms  nor  lesions,  however,  allow  of  any  en- 
tirely sharp  division,  since  intermediate  forms  occur.  The  following 
may  be  utilized  as  a  method  of  convenience  in  study:  (1)  The  ascitic 
form.  (2)  The  fibrous,  adhesive,  or  plastic  furtn.  (8)  The  caseous,  or 
ulcerative  form. 

These  varieties  arc  all  more  or  less  chronic  and,  as  stated,  shade  into 
each  other.  In  addition  there  is  the  development  of  miliary  tubercles 
upon  the  peritoneum  attending  cases  of  acute  general  miliary  tuberculosis, 
but  producing  no  certain  cHnical  manifestations,  and  not  considered 
here.  In  some  such  cases,  it  is  true,  the  al)d()minal  symptoms  predomi- 
nate, and  there  are  al)(loniinal  pain  antl  tenderness,  witii  rapid  devolop- 

'  Virohows  Archiv,  1892,  CXXVIII,  121. 


854  THE  DISEASES  OF  CHILDREN 

ment  of  effusion,  while  the  other  symptoms  arc  the  severe  constitutional 
manifestations  of  acute  miliary  tuberculosis  (p.  547).  Attention  will  be 
given  in  what  follows  to  the  chronic  forms  onl3^ 

1.  The  Ascitic  Form. — The  development  of  symptoms  may  be  entirely 
insidious,  or  ma}^  be  marked  by  gradually  increasing  loss  of  health,  flesh 
and  strength,  vague  or  slight  abdominal  pain  and  tenderness,  and  irregu- 
lar fever  of  moderate  degree.  There  may  be  vomiting,  but  this  is 
not  a  characteristic  symptom,  and  the  bowels  may  be  constipated  or 
unaffected,  or,  not  infrequently,  diarrheal.  There  is  nothing  on  which 
to  base  a  diagnosis  until  finally  attention  is  called  to  the  gradually 
increasing  distention  of  the  abdomen,  which  may,  indeed,  be  the  first 
symptom  of  any  sort  noted.  This  is  at  first  tympanitic,  but  later  ex- 
hibits fluid  free  in  the  abdominal  cavity,  and  giving  the  ordinary  signs 
of  fluctuating  dullness  in  the  flanks,  shifting  with  change  of  position, 
and  with  upward  displacement  of  the  diaphragm  and  of  the  hepatic 
dullness,  flattening  or  pouting  of  the  umbilicus,  and  dilatation  of  the 
abdominal  veins.  When  the  fluid  is  in  small  amount  careful  examina- 
tion may  be  required  to  show  its  presence,  and  the  distention  is  princi- 
pally tympanitic.  Sometimes  the  thickened  omentum  or  enlarged 
lymphatic  glands  can  be  detected.  The  fluid  is  usually  chiefly  serous, 
and  straw-colored  or  slightly  brownish. 

In  exceptional  cases  the  inflammation  may  begin  much  more  suddenly 
and  severely,  and  may  strongly  suggest  appendicitis  if  the  pain  and  other 
evidences  of  the  tuberculous  disease  are  at  all  marked  in  the  appendicular 
region. 

2.  The  Fibrous  Form. — This  is  of  more  frequent  occurrence  than  the 
ascitic  variety.  The  early  symptoms  are  very  similar  to  those  described, 
but  the  onset  is  even  more  gradual  and  the  development  slower.  Fever 
is  still  less  prominent  and  is  often  absent  (Fig.  275).  The  general  health 
is  at  first  little  affected.  Enlargement  of  the  abdomen  finally  attracts 
attention,  but  this  is  usually  found  to  be  tympanitic  in  nature.  Careful 
palpation  may  reveal  nothing  a})normal,  or  there  may  sometimes  be 
found  nodules,  or  areas  of  dullness  on  percussion  which  are  not  limited 
to  the  flanks  and  which  do  not  alter  with  change  of  position  of  the  patient. 
These  signs  depend  upon  the  development  of  tuberculous  deposits  in 
the  abdominal  wall,  in  the  intestines  bound  to  it,  in  the  omentum,  or  in 
the  me.senteric  glands,  or  sometimes  are  produced  by  fluid  confined  to 
a  certain  region  Ijy  adhesions.  In  some  cases  there  results  a  distinct 
alteration  of  the  shape  of  the  abdomen  as  determined  by  inspection. 
This  may  be  globular,  as  in  the  ascitic  form,  or  irregular  in  outline  depend- 
ent upon  the  presence  of  adhesions.  There  is  usually  little  or  no  fluid 
present,  but  sometimes  it  may  be  in  large  amount.  It  may  be  serous  or 
seropurulent.  Abdominal  pain  and  tenderness  are  absent  or  shght. 
The  formation  of  tuberculous  masses  or  of  firm  contracting  adhesions 
may  proceed  so  far  that  secondary  symptoms  result,  due  to  pressure 
upon  various  regions.  .  Among  these  are  edema  from  interference  with 
the  circulation;  digestive  disturbance  from  pressure  upon  the  intestine 
or  stomach;  intestinal  obstruction;  and  abnormal  urinary  conditions. 
Fibrous  peritonitis  may  be  such  from  the  beginning,  or  may  be  a  sequel 
to  the  ascitic  form  first  described.  The  chief  characteristic  is  the  de- 
velopment of  the  fibrous  exudate,  and  the  presence  of  many  large  nodules 
suggests  a  combination  with  the  caseous  type. 

3.  The  Caseous  or  Ulcerative  Form. — This  severe  type  of  tuberculous 
peritonitis  may  be  a  stvpiel  of  tlu;  others  described,  or  may  less  commonly 


TUBERCULOUS  PERITONITIS 


855 


exhibit  its  peculiarities  from  the  beginning.  Its  chief  characteristic  is 
the  formation  of  large  tuberculous  masses  and  smaller  nodules  which 
undergo  caseation  and  often  produce  pus.  Owing  to  this  and  to  the 
fact  that  a  tuberculosis  in  other  parts  of  the  body  is  generally  present  also, 
the  symptoms  earlj^  become  severe.  There  is  more  constant  and  greater 
elevation  of  temperature,  which  often  assumes  a  hectic  type  (Fig.  276) ; 


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ciation, anemia,  and  loss  of  strength  are  progressive  and  decided.  The 
abdomen  becomes  distended,  but,  altliough  fluid  wliicji  is  often  purulent 
may  Ix'  present  in  considerabje  quantities,  the  matting  of  the  intestines 
and  tlu!  presence  of  the  large  tul)erculous  masses  frequently  prevents 
the  discovery  of  this  by  percussion  or  bj''  palpation.  The  abdomen  may 
give  on  palpation  a  very  characteristic  sensation  of  doughy  resistance. 


856 


THE  DISEASES  OF  CHILDREN 


Pus  may  make  its  way  toward  the  umbilicus  or  elsewhere,  the  evidences 
of  beginning  abscess  of  the  abdominal  wall  being  clearly  visible. 

Course  and  Prognosis. — These  vary  greatly  with  the  nature  of 
the  lesion.  In  the  ascitic  form  without  marked  fibrous  change,  the  least 
severe  variety,  the  course  is  from  1  to  several  months.  In  favorable 
cases  the  effusion  varies  but  little  in  amount  from  time  to  time,  or  may 
exhibit  periods  of  temporary  diminution  or  increase;  but  finally  it  gradu- 
ally disappears  completely,  while  fever  lessens,  the  general  health  im- 
proves, and  recovery  takes  place.  Adhesions  may,  however,  remain, 
or  relapse  may  later  occur,  or  tuberculosis  make  its  appearance  in  other 
parts  of  the  body.     In  the  more  unfavorable  cases  emaciation  increases, 


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-TuBERCULOU.S  PERITONITIS,   CaSEOUS  FoKM,   WITH  HeCTIC  TyPE  OF 

Temperature. 


Elizabeth  R.,  aged  11  years.  Said  to  have  been  taken  ill  June,  1914.  Admitted  to  the 
Children's  Hospital  of  Philadelphia,  Dec.  15,  1914.  Operation  Dec.  29,  showed  fibro- 
caseous  tuberculosis  of  the  peritoneum.  Died  March,  1915.  Principal  symptoms  pro- 
gressive loss  of  health,  with  fever. 

and  death  takes  place  from  exhaustion  or  following  tuberculosis  of  some 
other  organ;  or  the  case  passes  into  the  fibrous  or  the  caseous  type. 

In  the  fibrous  form  the  course  is  slower,  lasting  several  months  or 
even  a  year  or  more.  It  may  then  slowly  undergo  recovery,  but  leaves 
adhesions  remaining,  even  after  apparent  cure;  and  there  is  a  decided 
tendency  to  relapse.  This  variety  may  prove  fatal  by  gradually  exhaust- 
ing the  patient;  or  it  may  pass  into  the  caseous  form  and  kill  through  the 
influence  of  pus-production ;  or  may  be  followed  by  the  development  of 
tuberculosis  elsewhere  in  the  body. 

The  caseous  form  is  of  shorter  duration  than  the  two  just  described, 
lasting  usually  only  a  few  months  after  evidences  of  the  breaking  down 
of  the  lesions  show  themselves.  The  duration  is  influenced  considerably  by 
the  course  of  the  tuberculosis  usually  present  in  other  parts  of  the  body. 


TUBERCULOUS  PERITONITIS  857 

The  prognosis  of  tuberculous  peritonitis  in  general  is  determined  bj^ 
various  circumstances,  such  as  the  inherent  strength  and  resisting  power  of 
the  patient;  the  type  of  the  disease;  the  age  of  the  child;  and  the  presence 
or  absence  of  tuberculosis  in  other  regions.  The  younger  the  patient, 
the  worse  is  the  prognosis.  In  Fletcher's^  163  cases  with  49  deaths,  35 
were  in  children  less  than  4  years  of  age.  Of  course,  the  presence  of 
tuberculosis  elsewhere  greatly  adds  to  the  Habihty  of  a  fatal  termination. 
The  prognosis  of  the  ascitic  form  is  not  as  unfavorable  as  formerly  be- 
lieved, now  that  the  treatment  of  the  malady  is  better  understood.  It 
is  in  this  type  especially  that  laparotomy  has  often  proven  of  value; 
but  that  it  accomplishes  all  that  was  at  first  claimed  for  it  is  doubtful, 
and  it  is  still  a  question  whether  the  results  obtained  by  it  are  superior 
to  those  with  non-operative  measures.  The  fibrous  type  gives  a  more 
unfavorable  prognosis,  and  certainly  the  larger  number  do  not  recover; 
not  so  much  from  the  existence  of  this  form  itself,  as  because  of  the  tend- 
ency to  pass  into  the  caseous  type,  or  to  give  rise  to  serious  complica- 
tions. Laparotomy  may  do  good  here  also,  but  less  is  to  be  expected 
than  in  the  ascitic  cases.  The  caseous  type  with  severe  constitutional 
symptoms  gives  a  most  unfavorable  prognosis,  but  is  yet  capable  of  cure, 
if  other  parts  of  the  body  are  not  involved. 

Regarding  the  statistical  prognosis  in  general  and  the  influence  of 
treatment,  statements  vary  to  a  considerable  extent;  and  are,  moreover, 
at  fault,  because  it  is  usually  not  known  in  how  many  instances  a  fatal 
relapse  or  a  development  of  tuberculosis  elsewhere  finally  occurred.  In 
general  the  proportion  of  final  complete  recoveries  might  be  placed  at 
approximately  30  to  50  per  cent.  As  regards  the  value  of  operative 
treatment,  one  of  the  earliest  and  most  favorable  series  is  that  of  Aldi- 
bert,2  of  52  children  operated  upon  with  7  deaths,  a  mortality  of  13.46 
per  cent.  Faludi^  reports  on  70  cases  of  which  46  were  operated  upon 
and  24  not.  Of  the  former  45.5  per  cent,  recovered,  and  of  the  latter 
20.83  per  cent.  Many  of  the  cases  were  watched  for  several  years  after 
operation.  Schramm^  in  45  cases  found  permanent  recoveries,  in  those 
which  could  be  traced,  in  20  per  cent,  of  those  treated  medically  and  75.4 
per  cent,  of  the  operated  cases.  Kissel^  reported  upon  54  cases,  35  of 
which  were  operated  upon,  with  27  recoveries;  i.e.  77.14  per  cent. 

In  favor  of  medical  treatment  is  the  report  by  Sutherland*'  of  41 
cases,  27  of  which  were  treated  medically,  with  recoveries  in  22;  i.e. 
81.3  per  cent  and  14  surgically,  with  7  recoveries;  i.e.  50  per  cent. 
Most  of  the  cases  were  under  observation  for  over  a  year.  Borchgre- 
vink^  in  22  cases  treated  medically  had  19  permanent  recoveries;  i.e. 
81.82  per  cent. 

Complications. — These  are  principally  the  occurrence  of  mani- 
festations of  tuberculosis  elsewhere  in  the  body.  Tuberculous  pleurisy 
is  not  infrequently  associated,  as  is  less  often  tuberculous  pericarditis, 
and  tuberculosis  of  the  meninges  or  of  the  lungs  is  a  not  unconimon  final 
cause  of  death.  The  genital  organs  are  only  occasionally  secondarily 
attacked  in  children.  Involvement  of  the  intestines  and  mosonteric 
glands  is  frequent.     To  be  noted  also  are  septic  processes  from  a  collec- 

1  Loc.  cit.,  250. 

2  Thdsc  de  Paris,  1892. 
^  Lor.  cit. 

*  Wiener  mecl.  Wocheiischr.,  1903,  LIII,  354. 

6  Arch.  f.  klin.  Cliir.,  1902,  LXV,  373. 

«  Arch,  of  Ped.,  1903,  XX.  81. 

'  Mittheil.  aus  der  Clreiizneb.  d.  Med.  and  Chir.,  1900,  VI,  434. 


858  THE  DISEASES  OF  CHILDREN 

tion  of  pus,  or  the  rupture  of  an  accumulation  of  this;  amyloid  changes 
in  the  liver  and  spleen;  and  intestinal  obstruction  or  other  pressure- 
symptoms  of  various  sorts  produced  by  the  fibrous  adhesions. 

Diagnosis. — This  is  by  no  means  easy  except  in  typical  and  well- 
advanced  cases.  Early  in  the  attack  it  is  usually  impossible.  It  rests 
principallj^  upon  slow  failure  of  health;  irregular  fever  without  dis- 
coverable cause;  slight  abdominal  pain  and  tenderness ;  and  finally  decided 
abdominal  enlargement  with  the  discovery  of  fluid  or  of  evident  thicken- 
ing of  the  abdominal  wall  and  the  presence  of  masses  beneath  it.  The 
existence  of  tuberculosis  elsewhere  in  the  body  is  suggestive.  The  em- 
plojanent  of  the  cutaneous  tuberculin  test  is  of  value  if  negative,  but  a 
positive  reaction  does  not  determine  that  the  abdominal  condition  is 
tuberculous.  Moreover,  severe  cases  maj-  have  lost  the  power  to  re- 
spond to  the  von  Pirquet  reaction.  The  examination  of  the  blood  is  of 
some  value,  there  being  in  tuberculous  peritonitis  an  absence  of  the  in- 
crease of  leucocytes  characteristic  of  most  inflammatorj'  conditions. 
Ascites  of  tuberculous  nature  is  to  be  distinguished  from  that  due  to  other 
causes.  That  dependent  upon  cardiac  or  rena.1  disease  is  accompained  by 
dropsy  elsewhere,  while  other  characteristic  symptoms  are  present  as  well. 
Atrophic  cirrhosis  of  the  liver  gives  diminution  in  the  size  of  this  organ, 
and  icterus  may  attend.  In  doubtful  cases  examination  of  the  fluid 
obtained  by  puncture  will  probably  show  in  tuberculosis  an  increase  in 
the  number  of  lymphocytes,  and  inoculation  experiments  will  produce 
the  disease  in  animals  (Durante).^  Puncture  is,  however,  a  procedure 
not  without  danger  of  perforation  of  the  intestine.  Tubercle  bacilli  are 
not  often  discovered  microscopically.  Chronic  non-tuberculous  peri- 
tonitis is  distinguishable  by  the  absence  of  discoverable  nodular  masses, 
and  of  so  decided  a  degree  of  emaciation  and  loss  of  health.  The  pre- 
sumption should  always  be  that  chronic  peritonitis  is  tuberculous  unless 
certainly  proven  otherwise.  Chronic  enteritis  with  diarrhea,  abdominal 
distention,  and  wasting  may  resemble  tuberculous  peritonitis,  but  the 
history  of  the  case  and  continued  observation  will  generally  remove  any 
doubt. 

Tuberculous  peritonitis  with  masses  discovered  through  the  abdominal 
wall  is  to  be  distinguished  from  abdominal  tumors  of  other  nature,  as  well 
as  from  fecal  accumulations  in  the  colon.  The  existence  of  other  symp- 
toms characteristic  of  tuberculosis  is  of  service  here.  That  the  disease 
is  of  the  caseous  type  is  rendered  pro))able,  when,  in  addition  to  the  pres- 
ence of  the  tuberculous  nodules  tliscovered  by  palpation,  there  are  decided 
abdominal  pain  and  tenderness,  tympanitic  distention,  and  severe  con- 
stitutional symptoms.  The  existence  of  tuberculosis  in  other  regions  aids 
in  the  diagnosis. 

Treatment. — The  medical  treatment  consists  in  the  employment 
of  all  measures  which  will  aid  the  patient  to  overcome  a  tuberculous 
process  of  any  nature.  (Seep.  562.)  Rest  lying  down  should  be  enforced, 
but  this  by  no  means  signifies  confinement  to  bed  in  the  house.  On  the 
other  hand,  the  patient  should  be  kept  in  the  open  air  as  much  as  possible 
and  preferably  removed  ta  some  climate  which  favors  this.  Sojourn  at 
the  mountains  and  especially  at  the  seashore  has  been  of  great  service  in 
many  instances.  The  diet  should  be  digestible  and  abundant,  and  there 
is  no  reason  to  abstain  from  a  highly  nitrogenous  regimen  because  fever 
is  present.  On  the  contrary,  the  food  should  be  stimulating.  The 
presence  of  diarrhea  and  other  digestive  disturbances  often  renders 
'La  Pediatria,  1901,  IX,  437. 


ASCITES  859 

satisfactory  feeding  difficult;  yet  sufficient  nourishment  is  one  of  the 
most  important  therapeutic  factors.  Alcohohc  stimulants  may  be  given 
as  required.  Local  application  of  mercurial  ointment,  of  ichthyol,  and 
of  iodoform  have  been  recommended,  as  has  been  the  exposure  of  the 
abdominal  walls  to  the  direct  rays  of  the  sun.  The  internal  adminis- 
tration of  creosote  and  of  iodoform  have  each  their  adherents.  Tonic 
remedies  may  be  needed,  including  cod-liver  oil  if  it  is  well  tolerated, 
and  such  treatment  also  as  complications  demand.  In  general,  however, 
the  chief  dependence  is  to  be  placed  upon  hygiene  and  diet.  What 
benefit  is  to  be  gained  by  the  injection  of  tuberculin  is  still  an  unsettled 
question.  There  is  some  reason  to  believe  that  it  is  of  more  value  here 
than  in  some  other  forms  of  tuberculosis,  but  further  experience  is 
demanded. 

Operative  interference  in  the  form  of  laparotomy  is  to  be  seriously 
considered  in  the  light  of  the  data  given  regarding  it.  Certainly  it  seems 
to  be  of  great  possible  value  if  done  early  in  the  ascitic  cases,  and  since 
the  danger  of  operation  is  slight  and  that  of  the  disease  itself  great,  and  as 
recovery  from  the  disease  is  often  very  prompt  after  it,  it  should  be  recom- 
mended in  all  cases  of  this  type,  if  a  few  weeks  of  thorough  hygienic  and  diet- 
etic treatment  have  been  without  influence.  In  the  purely  fibrous  form 
without  tuberculous  masses  recovery  may  take  place  spontaneously;  but 
even  here  laparotomy  may  do  much  good  and  can  do  little  harm.  Cases 
where  a  small  localized  or  more  generalized  accumulation  of  pus  can  be 
discovered  require  operation. 

TUMORS  OF  THE  PERITONEUM 

These  are  of  occasional  occurrence  in  early  life  and  may  be  either 
malignant  or  benign  in  nature;  primary  or  secondary.  Cysts  of  various 
sorts  are  sometimes  found  including  dermoid,  hydatid,  chjdous  and  serous: 
They  are.oftencst  in  the  mesentery.  Carcinoma  is  very  rare -even  when 
secondary.  Sarcoma,  fibroma,  angioma  and  lipoma  may  occur.  The  last 
has  sometnnes  attained  a  largo  size. 

ASCITES 

By  this  title  is  designated  an  accumulation  of  fluid  in  the  general 
peritoneal  cavity.  The  condition  is  not  a  disease,  but  a  symptom  depend- 
ent upon  various  causes.  It  is,  however,  sufficiently  common  and  impor- 
tant to  warrant  separate  brief  consideration.  The  fluid  may  be  entirely- 
clear  and  either  colorless  or  of  a  yellowish  tint;  or  it  may  be  more  or  less 
hemorrhagic  or  contain  flakes  of  lymph  and  other  evidences  of  inflamma- 
tion. Microscopically  it  may  show  either  few  cellular  elements  when  it  is 
of  the  nature  of  a  transudate,  or  many  when  the  cause  is  a  local  inflamma- 
tory condition.  If  the  inflammation  is  a  tuberculous  peritonitis,  the  lym- 
phocytes are  in  excess;  if  an  acute  peritonitis  dependent  upon  other  germs, 
the  polymorphonuclear  cells  predominate. 

Among  the  causes  may  be  mentioned  peritonitis  of  various  sorts,  as 
the  tuberculous  and  the  non-tuberculous  fonns,  including  polyserositis; 
cirrhosis  of  the  liver,  a  rare  cause  in  early  life;  ol)structioii  to  the  portal 
circulation  fiom  other  sources,  such  as  pressure  of  a  tumor  or  of  an  en- 
larged lymphatic  gland ;  great  anemia ;  and  renal  or  cardiac  disease.  These 
last  two  are  the  most  common  causes.  It  may  also  develop  without 
discoverable  agency  and  be  associated  with  hydrothorax  and  anasarca, 
as  in  the  essential  edema  of  children. 


860  THE  DISEASES  OF  CHILDREN 

Ascites  may  in  rare  cases  be  congenital,  is  uncommon  in  infancy, 
somewhat  less  so  in  early  childhood,  and  begins  to  be  observed  oftener  in 
later  childhood.  The  symptoms  are  similar  to  those  seen  in  adult  life. 
The  abdomen  is  distended;  there  is  often  flattening  or  pouting  of  the 
umbilicus;  fluctuation  on  palpation,  with  a  distinct  wave-like  impulse 
obtained  by  sharp  tapping  with  the  hand;  and  dullness  on  percussion 
which  shifts  with  change  of  position  unless  the  amount  of  fluid  is  very 
large. 

The  course,  prognosis  and  treatment  depend  entirely  upon  the  cause. 

Chylous  Ascites. — This  is  an  uncommon  form  of  ascites  at  any  time 
of  life.  The  causes  are  variable.  In  the  instances  of  true  chylous 
efifusion  there  has  been  an  injury  to,  or  pressure  upon,  the  thoracic  duct 
or  some  of  its  tributaries,  as  a  result  of  which  the  chyle  has  entered  the 
abdominal  cavity.  In  these  cases  the  fluid  has  the  appearance  of  milk 
and  contains  fat-cells  in  very  large  numbers.  In  other  cases  the  fluid  is 
chyliform  only,  and  the  condition  depends  upon  tuberculous  or  non- 
tuberculous  chronic  peritonitis,  and  the  color  appears  to  be  the  result  of 
degeneration  of  the  inflammatory  products,  since  cells  showing  evidences 
of  this  are  discoverable.  Chylous  ascites  has  also  been  produced  by  the 
rupture  of  a  mesenteric  cyst.  The  prognosis  is,  as  a  rule,  unfavorable; 
yet  recovery  after  operative  interference  has  been  reported  (Huber  and 
Silver).  1 

1  Amer.  Journ.  Dis.  Child.,  1914,  VIII,  50. 


INDEX 


.\bdomen  in  infancy,  37 

symptoms  connected  with,  200 
Abdominal  band,  71 
Abscess,  alveolar,  651 
of  gums,  651 
hepatic,  842 
ischiorectal,  815 
of  liver,  842 
peri-esophageal,  695 
peritoneal,  846,  853 
perityphUtic,  802 
retro-esophageal,  695 
retropharyngeal,  676 
subphrenic,  851 
Absorption  of  carbohvdrate,  49,  50 
of  fat,  48,  50  -  >      > 

of  food,  45,  48 
from  intestine,  45,  49,  51 
of  protein,  50 
of  salts,  51 
Acetonuria  in  diabetes,  639 
in  newborn,  61 
in  recurrent  vomiting,  708 
Acholuric  icterus,  835 
Acid,  hydrochloric,  action  of,  43 

early  secretion  of,  43 
Acidosis,  635 
causes  of,  636 
in  diabetes,  639 

distinction  from  acetonuria,  635 
in  gastro-enteric  intoxication,  698,  741 
soda  solution  in,  232 
treatment,  636 
Adenitis,  acute  simple,  in  adenoid  vege- 
tations, 688 
in  diphtheria,  447 
in  grippe,  478 
in  lymphatism,  633 
in  measles,  344 
in  mumps,  500 
in  pharyngitis,  671,  675 
in  retropharyngeal  abscess,  076 
in  rubella,  358 
in  scarlet  fever,  324 
in  stomatitis,  ()53,  654,  6()2 
in  syphilis,  571,  577 
in  tonsillitis,  680,  682 
in  hypertrophy  of  faucial  tonsils. 
685 
tuberculous,  55() 
Adenoid  vegetations,  686 

bony  deformities  from.  688 
causing  cervical  adenitis,  688 
deafness  from,  6,S8 
niouMi-breatliing  from,  (»S7 
sli;ip(;  of  iiosL'  in,  ().S7 
Adolescence,  19 
Affusion,  241 


861 


Air,  amount  required  in  room,  79 

exposure  to,  76 
Airing,  76 
Albulactin,  168 
Albumen- water,  150 
Albumin-milk,  148,  168 
Albuminuria  in  diphtheria,  447,  454 
in  measles,  349 
in  newborn,  61 
in  pertussis,  486 
in  scarlet  fever,  326 
in  variola,  372 
Alcohol,  223 

influence  on  breast-milk,''84,  106,  107 
.Ihmentary  intoxication,  698,  741 
Alopecia,  syphiUtic,  570 
Amusements,  77 
Amylaceous  foods,  152 
Amyloid  degeneration  of  liver,  841 
Anaphylaxis  to  proteins,  131 
Anatomy,  17 
Anesthetics,  248 
Angina,  671.     See  Pharyngitis. 

Plaut-Vincent's,      682.     See       Ulcero- 

m e m branous  tonsillitis . 
simple,  671 
Ankylostoma,  828 
Anorexia,  705 
nervosa,  706 
Antipyretic  drugs,  224,  228 
Anus,  congenital  stenosis  and  atresia  of, 
783 
fissure  of,  814 
fistula  in,  815 
prolapse  of,  811 
pruritis  of,  816 
Aphonia  in  diphtheria,  454 
Ai)litluB,  653.     See  Aphthous  stomatitis. 

Bednar's,  664 
Appendicitis,  800 
catarrhal,  802 
chronic,  803 

course  and  prognosis,  806 
diagnosis,  S07 
etiology,  800 
gangrenous,  803 
in  infancy,  803 
pathological  anatomv,  801 
perforative,  803 
recurr(>nt,  803 
supj)urative,  802 
symptoms,  802 
treatment,  809 
varieties  of,  802 
Applications  to  no.se  ;iii(l  lluo.'it,  2:^7 
.Vriowroot,  155 
.Arsenic,  225 

passage  into  niiik,  I  (Hi 


862 


INDEX 


Arteries,  inflammation  of,  290 
Arteritis,  umbilical,  290 
.\i-thritis,  rheumatic,  622 
rheumatoid,  624 
in  scarlet  fever,  325 
Arthritism,  631 

Artificial    feeding,    108.     See    also    Diet, 
feeding,  etc. 
albumen- water,  150 
al])umin-milk,  148,  168 
amylaceous  foods,  1 52 
beef-juice,  150,  165 
beef-tea,  151 

carbohydrate  foods,  152,  156 
casein-flour,  154 
casein-milk,  148 
dextrinized  foods,  155 
in  chronic  diarrhea,  757 
Eiweiss-milk,  148 
equation  for  obtaining  percentages, 

140 
in  acute  gastro-enteric  intoxication, 

744,  747 
by  gavage,  247 
gelatin,  152 
in  hot  weather,  743 
in  acute  ileocolitis,  753  I 

in  illness,  728  | 

in     chronic     intestinal    indigestion,   \ 
768  ' 

meat-broths,  151 

to  calculate  percentages  in  any  milk- 
mixtures  in  use,  143 
general  principles  of,  119  ' 

protein  foods,  150  I 

protein  milk,  148  | 

quantity  required,  133 
ready    reference    card    for    making 

milk-formulae,  142 
soy-bean  flour,  152 
special      mixtures      with      personal  -" 

names,  158 
table  of  percentage-strengths  of  dif 
ferent  layers  of  milk,  139 
respiration,  methods  of,  280 
Ascaris  lumbricoides,  819 
Ascites,  859 

chylous,  8()0 
-Vsphyxia  in  diphtheria,  450 
neonatorum,  276 

extrauterine,  277,  278 
intrauterine,  276,  277 
livida,  278 
pallida,  278 
treatment,  280 
of  newborn,  276 
from  overlying,  217 
in  pertussis,  489 
in  retropharyngeal  abscess,  678 
Aspiration  of  the  tongue,  217 
Asthenia,  congenital,  286 
Asthma  with  adenoid  growths,  688 

in  exudative  diathesis,  631 
Astringents,  228 

Atelectasis  in  congenital  asthenia,  286 
in  newborn,  284 
in  premature  infants,  254 
Athrepsia,  610 


Atrophy,  acute  yellow,  837 
infantile,  610 
etiology,  611 
hypertonia  in,  613 
symptoms,  612 
treatment,  614 
Atropine,    225.     See   also    Belladonna. 
Auscultation,  190 
indications  from,  199 

Backhaus'  milk,  159 
Backwardness  from  adenoid  growths,  688 
Bacteria  in  cow's  milk,  113 
removal  of,  125 

of  feces,  48 

in  human  milk,  100 

of  intestine,  45 

of  mouth,  45 

of  stomach,  45 
Balance,  disturbance  of,  697 
Band,  abdominal,  71 
Bauer's  formulse,  138 
Barley-water,  153,  154 
Barlow's  disease,  602 
Basket,  Baby's,  69 
Bath,  first,  after  birth,  68 

blanket,  242 

bran,  243 

cool,  240 

disinfecting,  243 

foot,  243 

graduated,  240 

hot,  240 

hot-air,  242 

in  later  infancy  and  childhood.  69 

medicated,  242 

mineral  water,  243 

mustard,  242 

salt,  243 

sheet,  241 

shower,  241 

soda,  243 

sponge,  239 

starch,  243 

sulphur,  243 

temperature  of,  in  disease,  239 
in  health,  69 

tepid,  240 

tub,  240 

vapor,  242 

warm,  240 
Bean- flour,  155 
Bedding,  75 
Bednar's  aphthse,  664 
Beef,  minced,  151 

peptonized  preparations,  165 
Beef-extracts,  165 
Beef -juice,  150 

commercial,  165 
Beef-powders,  165 
Beef-tea,  151 
Belladonna,  225 

passage  into  milk,  106 
Biedert's  cream-mixtures,  158 
Bile,  action  of,  in  digestion,  45 

secretion  of,  42 
Bile-ducts,  congenital  obliteration  of,  273 

in  catarrhal  icterus,  833 


INDEX 


863 


Bile-diicts,  disease  of,  843 
Biliousness,  832 
Black  tongue,  66G 
Bladder,  control  of,  65 

teaching,  77,  78 
Blindness  in  ophthalmia,  297 

in  pertussis,  488 
Blood  in  cerelirospinal  fever,  424 

circulation  of,  in  fetus,  56 

in  e^irly  life,  58 

hemoglobin,  58 

in  hemolytic  icterus,  837 

indications  derived  from  study  of,  207 

in  measles,  344 

in  mumps,  499 

in  pertussis,  486 

in  scarlet  fever,  317 

transfusion  of,  246 

in  tuberculosis,  559 

in  typhoid  fever,  398 
Blood-cells,  varieties  and  description  of, 
58 

erythrocytes,  58 

leucocytes,  59 
Blood-letting,  245 

Blood-pressure,  in  early  life,  57,  58,  192 
Blood-vessels.     See  Arteries  and  Veins. 

changes  after  birth,  56 

ductus  arteriosus,  56 

ductus  venosus,  56 

in  early  life,  55 

in  fetus,  55 

umbilical  arteries  and  veins,  56 
Body,  surface  of,  32 
Bones,  lesions  of,  in  rickets,  586 

in  syphilis,  562,  571,  .574 
Bothriocephalus  latus,  826 
Bottles,  nursing,  135 
Bottom-milk,  1 17 

Bowel-movements.     Hec- Stools  and  feces. 
Brachial  fistulae,  691 
Brain,    weight   of,    at   different   periods, 

64 
Breast,  early  secretion  in,  60 
Breast-feeding,  82 

ability  of  mothers,  82 

advantages,  82 

amount  of  milk,  86,  92 

causes  making  inadvisable  or  impos- 
sible, 86 

hygiene  of  mother,  84 

intervals  for,  85 

preparation  for,  before  birth  of  child,  83 

mles  for,  84 

signs  of  \msatisfactory  results,  87 
Breast-milk,  92.     See  Milk,  human. 
Breath,  indications  derived  from,  204 
Breathing.     See  Respiration. 
Breck  feeder,  25t) 
Bromides,  225 

passage  into  milk,  10() 
Broths,  meat,  151| 
Buhl's  disease,  2()0 
Buttermilk,  147 

in    acute    gastro-enteric    intoxication, 
744 

in  ileocolitis,  754 

in  ('hronio  intestinal  indigestion,  768 


Calculus,  biliary,  844 
Caloric    method    of    feeding,    121.     See 
Feeding. 
values,  cow's  milk,  99,  110 
human  milk,  99 
various  foods,  174-177 
various  cooked  foods,  175 
Calories,  method  of  calculating,  52,  122, 
123 
equivalent  of  different  food-elements, 

53,  122 
numi)er  required  in  first  year,  52,  53, 
121 
after  first  3'ear,  173 
utilizable,  53 
Cancrum     oris,     659.     See     Gangrenous 

stomatitis. 
Caput  succedaneum,  271 
Carbohydrates,  49,  50.     See  also  Starch 
and  Sugar. 
absorption  of,  49 
effect  on  digestion  of  fat,  50,  129 
effect  on  digestion  of  protein,  50,  129 
in  feces,  732 
of  food,  49,  152 
Cardiac  rheumatism,  622,  625 
Cardiospasm,  714 
Cariole,  76 

Carriers,  importance  of,  in  infectious  dis- 
eases, 306 
management  of,  in  diphtheria,  462,  471 
Casein  in  digestion,   95,    109.     See  also 
Protein. 
in  cow's  milk,  112 
in  human  milk,  96 
relation  to  lactalbumin,  96,  112 
in  various  mammalian  milks,  108 
Casein-floiir,  153 
Casein-milk,  148 
Catarrh  of  Eustachian  tube  in  adenoids, 

688 
Cavities,  puhnonarj-,  in  phthisis,   556 
in    tuberculous    bronchopneumonia. 
551 
Cellulitis  in  diphtheria,  452 
in  erysipelas,  441 
in  mumps,  497 
in  scarlet  fever,  324 
in  sepsis  in  newborn,  259 
in  tuberculous  peritonitis,  856 
Centrifugal   machine,    Babcock's,    103 

Leff  man- Beam,  103 
Cephalhematoma,  269 
Cereal-decoctions,  various,  153 
Cereal-gruels,  dextrinized,  155 

table  of  strengths,  154 
Cereals  for  use  at  different  ages,  170,  171. 
172 
percentage    composition     and     c'lloiir 
values,  175,  177 
Cerebrospinal  fever,  415 
abortive  form,  425 
blood  in,  424 
chronic,  425 
combination    witli    other    infectious 

diseases.  429 
coin|)lications  ;\nd   sequels,   426 
cutaneous  syinptonis,  422 


864 


INDEX 


Cerebrospinal  fever,  diagnosis,  431 
digestive  symptoms,  422 
ears  in,  427 
etiologjs  416 
eyes  in,  427 
fulminating,  425 
germ  of,  410 
incubation,  418 
intermittent,  426 
invasion,  418 
lumbar  puncture  in,  424 
malignant,  425 
mild  form,  425 
nephritis  in,  429 
nervous  symptoms,  420,  428 
ordinary  form,  418 
pathological  anatomy,  417 
pneumonia  in,  429 
prognosis,  431 

relapse  and  recurrence,  430,  431 
severe  form,  425 
spinal  fluid  in,  424 
symptoms,  418 
cutaneous,  422 
digestive,  422 
nervous,  420,  428 
temperature  in,  422 
throat  in,  428 
transmission,  417 
treatment,  433 
prophylaxis,  433 
serum,  433 
meningitis,     415.     See     Cerebrospinal 
fever. 
Certified  milk,  118 

Cervical  glands.     See  Lymphatic  glands. 
Chapin  dipper,  116 
Chest,    circumference   of,    35.     See   also 

Thorax. 
Childhood,  18 
carlv,  18 
later,  18 
Chloral,  225 
Cholecystitis,  844 
Cholera  infantum,  741 

nostras,  741 
Chorea,  as  manifestation  of  rheumatism, 

622,  625 
Circulation,  fetal,  56 

changes  in,  after  birth,  56 
organs  of,  54 

rapidity  of,  in  childhood,  56 
Cirrhosis  of,  liver,  838.     See  also  Liver. 

congenital  biliary,  273 
Cleft  palate,  670.     See  also  Palate,  cleft. 
Climatotherapy,  250 
Clothing,  character  of,  71 
of  childhood,  74 
first  for  infancy,  71 
night,  in  childhood,  74 
weight  of,  26 
Cod-liver  oil,  225 
C celiac  disease,  772 
Cold,    dry,   240,    244.     See   also    Flydro- 

therapy. 
Colic,  728 
diet  in,  179 
gastric,  704 


Colitis,  747.     See  also  Ileocolitis. 
Collapse  of  lung.     See  Atelectasis. 
Colles'  law,  564 

Colon,  dilatation  of,  idiopathic,  777 
secondary,  778 

hypertrophy  of,  777 

inflammation  of,  748,  755 

irrigation  of,  233 

in  chronic  intestinal  indigestion,  765, 
771 

in  rickets,  597 

congenital  stenosis  and  atresia  of,  781 
Colostrum,  93 

Commercial  foods,  160.     See  Foods,  pro- 
prietary. 
Compresses,  244 

Condensed   milk,    161.     See  Foods,  pro- 
prietary. 
Congenital  diseases.     See  also  Malforma- 
tions. 

erysipelas,  436 

malaria,  502 

patulous  Meckel's  diverticulum  open- 
ing at  umbilicus,  295 

rickets,  598 

syphilis,  564 

tuberculosis,  539 

typhoid  fever,  400 

variola,  365 
Conjunctiva,   hemorrhage  from,  in  new- 
born, 265 

in  pertussis,  488 
Conjunctivitis,  diphtheritic,  453 

in  measles,  349 
Constipation,  757 

in  appendicitis,  805 

diet  in,  179 

in  dilatation  of  colon,  778 

etiology,  758 

in  fissure  of  anus,  815 

in  chronic  intestinal  indigestion,  772 

in  intestinal  obstruction,  781 

in  intussusception,  787 

in  pyloric  stenosis,  710 

in  rickets,  597 

symptoms,  759 

treatment,  760 

in  recurrent  vomiting,  703 
Cord,  spinal,  at  birth,  64 

umbilical,  dressing  of,  72 
falling  of,  37 
ligation  of,  68 
Corj'za  in  measles,  339 

in  syphilis,  571 
('ough,  indications  derived  from,  203 
C'ounter-irritation,  238 
Coverings  during  sleep,  76 
Cow's  milk,   108.     See  Milk,  cow's. 
Craniotabes  in  rickets,  587,  592 

in  syphilis,  572 
Cream  for  constipation,  128 

of  cow's  milk,  115 

of  human  milk,  95,  99,  102 

effect  of  pasteurizing  on,  127 

different  strengths  of,  115,  139 

cream-whey  mixtures,  145 
Cream-gauge,  102,  110 
Creeping-apron,  73 


INDEX 


865 


Croup,  diphtheritic,  449 

true.  449 
Croup-kettle.  237 
Croup-tent,  236 
Cry,    varieties    and    indications    derived 

from,  202 
Cupping,  239 

Cyanosis  in  acute  fatty  degeneration  of 
the  newborn.  261 
infectious  hemoglobinemia,  263 

in  asphyxia  neonatorum,  278 

in  atelectasis,  285 

in  diphtheritic  laryngitis,  450 
Cyclic    vomiting,     701.     See     Recurrent 

vomiting. 
Cysticercus.  824 

Deaf-mutism,  427 

Deafness  from  adenoid  growths,  688 

in  cerebrospinal  fever,  427 

in  mumps.  500 

in  scarlet  fever,  324 

in  later  symptoms  of  hereditary  syphi- 
lis, 577 

in  typhoid  fever,  408 
Death,  causes  of,  at  different  ages,  214. 
See  also  Mortality. 

sudden,  216,  632 
Debility,  congenital,  286 
Decomposition,  alimentary,  698,  763 
Dental  caries,  652 
Dentition,  37,  650.     See  also  Teeth. 

delayed,  650 

difficult,  651 

early,  650 

eruption  of  first  teeth,  37 
of  permanent  set,  37,  38 

irregularities  of,  650 

period  of  first,  18 
of  .second,  18 
Development,  20 

of  body,  64 

defects  in.     Sec  Malformations. 

of  mental  powers,  66 

of  muscular  power,  64 

of  nervous  functions,  65 

of  reflexes,  65 

of  special  senses,  65 
Dextnnizcd  gruels,  155 
Dextrin-maltos(!  preparations,  129,  155 
Diabetes  insipidus,  641 

mellitus,  637 
etiology,  638 
prognosis,  639 
treatment,  640 
Diagnosis,     general,     metliods    of,     183, 

194 
Diapers,  71 
Diarrhea,  733 

variety  of  causes  (»f.  734 

cholera  infantum,  741 

choleriforin,  741 

chronic,  755 

general  considerations,  733 

influence  of  artificial  feeding,  212 

from  acute  intestinal   indigestion,   737 

from  clironic  intestinal  indigestion,  7(5 1. 
772 


Diarrhea,  inflammatory,  735,  747 

mechanical  or  chemical  causes,  734 

of  metabolic  origin,  735 

mortality  from,  212,  733 

nervous,  735 

influence  of  season,  213,  733 

summer,  738 

toxic,  735 
Diathesis,  exudative,  630 

lymphatic,  632 
Dibothriocephalus  latus,  826 
Diet.     See  also  Feeding  and  Food. 

in  first  year,  82,  108 

from  12  to  18  months,  169 

from  18  to  24  months,  170 

from  2  to  3  years,  171 

from  3  to  6  years,  172,  173 

in  colic,  179 

in  constipation,  179,  760 

in  diarrhea,  179 

in  chronic  diarrhea,  757 

in  diabetes,  640 

in  acute  gastric  indigestion,  720 

in  chronic  gastric  indigestion,  180,  726 
gastritis,  726 

in  acute  gastro-enteric  infection,   744 
ileo-colitis,  753 

in  illness,  178 

in  infantile  atrophy,  611,  614 

influence  of,  on  mother's  milk,  105 

in  acute  intestinal  indigestion,   737 

in  chronic  intestinal  indigestion,  767, 
774 

in  rickets,  584,  601 

in  scurvy,  603,  610 

in  vomiting,  178 
Digestion     in     infancy,     43.     See     also 
Absorption  and  Metabolism. 
gastric,  43 
intestinal,  44 
Digestive  tract,  bacteria  of,  45 

gases  of,  46 
Digestive  system,  diseases  of,  648 

in  early  life,  37 
Dilatation  of  colon,  777 

of  esophagus,  692 

of  stomach,  714 
Diphtheria,  443 

anemia  as  sequel  of,  445 

bacillus  of,  444 
avirulent,  445 
pseudo-,  445 

blood  in,  448 

of  bronchi,  453 

br()nch()|)neuinonia  in,  453 

cardi.'ic  failure  in,  453 

managetnent  of  carriers,  462,  471 

catarrliai,  451 

complications  and  sequels,  453 

of  conjunctiva%  453 

convalescence,  448 

diagnosis,  bacteriological,  459 
clinical,  458 

erythema  in,  455 

of  esophagvis,  693 

etiology,  443 

eyes  in,  454 

faucial,  447 


866 


IXDEX 


Diphtheria,  heart  in,  453 
history-,  443 
ileocolitis  in.  455 
natural  immunity.  443.  460 
immunization.  4(U 
incubation,  447 
individual  susceptibility,  443 
intestine  in,  453 
intubation,  466 
invasion,  447 
lacunar,  451 
laryngeal,  449 
lesions,  local,  445 

of  organs,  446 
malignant,  452 
mild,  451 

mortality  of,  456,  457 
of  moutii,  453 
nasal,  449 

nasopharyngeal,  449 
nephritis  in,  454 
other  infectious  diseases  in.  455 
otitis  in,  455 

pathological  anatomy,  445 
paralysis  in,  454 
of  penis,  453 
pneumonia  in,  453 
prognosis,  456 
prostration  in,  448 
pseudo-,  674 
pulse,  447 
quarantine,  461 
recurrence,  456 
reflexes  in,  454 
relapse  in,  455 
Schick  reaction,  460 
septic,  452 

serum  disease  in,  464 
severe,  452  i 
of  skin,  453 
swallowing  in,  454 
symptoms,  447 
temperature  in,  447 
thrombosis  in,  455 
tonsillar,  447,  451 
tracheotomy  in,  466 
transmission,  445 
treatment,  antitoxin,  456.  462,  464 

of  attack,  462 

of  carriers,  462,  471 

of  complications  and  sequels,  471 

of  convalescents,  471 

operative,  466 

prophylactic,  460 

unfavorable  effects  of  antitoxin.  464 
unusual  localizations,  452 
urine  in,  447 
of  vagina,  453 
voice  in,  4.54 
Diphtheria-antitoxin,  456,  461,  462 
dosage  of,  463 
immunization  wfth,  461 
influence  of  time  of  administration,  457 
success  of,  456 

toxin-antitoxin  administration,  461 
unfavorable  effects  of,  464 
units,  462 
Dipylidium  caninum,  825 


Disease,  characteristics  of,  in  early  life,  182 

etiology  of,  in  early  life,  182 

mortality  in,  211 

tendency  to,  at  different  ages,  209,  210 

therapeutics  in,  219 
Disinfection  of  patient,  243,  308 

of  room,  308 
Disturbance  of  balance,  697 
Diverticulitis,  810 
Divisions  of  life,  17 
Dress,  71.     See  Clothing. 
Dressing,  method  of,  72 
Dropsy.     See  Edema. 
Drugs  administered  bv  mouth,  220 

antipyretic,  224,  228 

dosage,  222 

approximate     average     of     various 

drugs,  table.  229 
proportionate    for    age,    table,    222, 

223 
table  of,  for  1  year,  229 

effect  and  degree  of  susceptibility  to 
certain,  223 
on  milk  of  mother,  106 

grouped  according  to  action,  228 

measurement  of.  219 

method  of  giving  by  mouth,  220 

purgative,  228 

sedative,  228 

stimulants.  223,  229 

tonic,  229 
Duodenum,  stenosis  or  atresia  of,  781 

ulcer  of,  797 
Dysentery,  747.     See  Ileocolitis. 
Dyspepsia.  Finkelstein's,  698,  736.     See 
also  Indigestion. 

intestinal,  763 
Dysphagia  in  quinsy,  683 

in  retropharyngeal  abscess,  677 

in  spasm  of  esophagus,  692 

in  stricture  of  esophagus,  692,  694 
Dyspnea  in  acidosis,  636 

in  laryngeal  diphtheria,  450 

in  retropharyngeal  abscess,  677 

significance  of  as  symptom,  200 

Ears  in  measles,  349 

in  mumps,  .500 

in  newborn,  34 

in  scarlet  fever,  323 
Eclampsia  as  cause  of  death,  214,  218 

in  pertussis,  488 

significance  of,  207 
Edema  in  erysipelas,  436 

in  infantile  atrophy,  613 

in  injurv  from  excessive  starchv  diet, 
617    " 

in  malnutrition,  617 

marantic,  613 

significance  of,  196 
Edema-neonatorum,  301 
Eiweiss-milk,  148 
Electrical  reactions,  193 
in  poliomyelitis,  528 
Electricity,  therapeutic  use  of,  250 
Embolism  in  diphtheria,  455 
Emphysema  in  pertussis,  484 

subcutaneous,  in  diphtheria,  455 


IXDEX 


867 


Endocarditis  in  chorea,  625 

in  rheumatism,  622,  625 
Enemata,  233 

in  coHc,  730 

in  chronic  diarrhea,  757 

in  dilatation  of  colon.  781 

in  constipation,  761 

in  ileocolitis.  754 

nutrient.  181.  233 

to  reduce  fever.  234 
Energy-metabolism.  52 
Energy-quotient,  53.  121 
Enteralgia.  728 

Enteritis,  follicular.  747.     See  Ileocolitis. 
Enteroclysis,  235 

Enterocolitis,  747.     See  Ileocolitis. 
Epiphyses,  enlargement  of,  in  rickets,  587 

separation  of,  604 
Epiphysitis,  syphilitic,  571 
Epistaxis  in  malaria.  510 

in  pertussis.  488 

in  typhoid  fever,  400.  406 
Epitrochlear  glands  in  syphilis.  591 
Epulis,  648 
Erysipelas.  436 

diagnosis,  442 

etiology,  436 

incubation.  437 

in  early  infancy,  439 

neonatorum,  439 

pathological  anatomy,  436 

prognosis,  441 

relap.se  and  recurrence.  441 

.symptoms,  437 

treatment,  442 
Erythema  in  diphtheria,  455 

in  grippe,  479 

infectiosum,  363 

in  rheumatism,  626 

after  serum  injections,  435,  465 

in  typhoid  fever.  409 

in  varirella,  384 

in  variola,  367 
Esophagismus,  692 
Esophagus,    ab.scess    behind      695 

acquired  dilatation  of,  694 

congenital  dilataticm  of.  692 

diphtheria,  of.  453,  693 

diseases  of,  691 

diverticula  of,  691 

foreign  bodies  in,  695 

in  infancy,  40 

malformations  of.  ()91 

spasm  of,  692 

congenital  stenosis  and  atresia.  6<.n 

stricture  of,  693 

thrush  in.  655 

tracheal  fistula  into,  692 
Esophagi! is,  catarrhal.  693 

corrosive,  693 

diphtheritic.  693 

follicular.  693 
Etiology  in  early  life,  182 
Eucasin.  167 
Examination,  auscultation,  190.  199 

detailed  methods  of,  185 

electrical.  \9'.i 

general  methods  of.  183 


Examination,  inspection.  186 
palpation.  188 
percussion,  189.  199 
puncturing  serous  cavities,  192 
radioscopv.  193 
reflexes.  193 

temperature-taking.  191 
obtaining  urine.  192 
Exercise  for  infants.  77 
for  older  children,  77 
of  mother,  83,  84,  107 
Expression,  indications  derived  from,  196 
Extremities,  19,  37 

relation  to  head  and  thorax.  31 
Eyes,    hemorrhage    behind,    in    .scui-vv, 
608 
in  measles.  349 
in  newborn.  34 

shrinking  of  tissues  about.   197 
in  infantile  atrophy.  613 
in  acute  inanition.  616 
in    acute   gastro-enteric    intoxica- 
tion. 741,  742 
toilet  of,  in  infancy,  68,  70 

Face  and  expression,  indications  derived 

from,  196 
Facial  hemiatrophy  in  poliomyelitis.  530 
Fat,  absorption  of.  48,  49 

action  of,  in  food,  49.  99,  128 

as  cause  of  illness,  178 

in  cow's  milk.  111,  128 

determining  amount  of,  110 

danger  from,  in  diabetes,  640 

danger  in  chronic  intestinal  indigestion, 
764 

in  feces,  46 

function  of,  in  food,  49,  99,  128 

in  human  milk,  95,  99 

determining  amount  of,  in  human 
milk,  102 

metabolism  of,  48 

percentages      of      different      strength 
creams,  115 
in  various  food-stuffs,  175 
in  top-milk.  139 
Fat-free  milk,  117 

Fatty  degeneration  of  newl)orn.  2(iO 
Fecal  concret  ons.  817 
Feces,  abnormal,  731 

bacteria  of,  48 

blood  in,  732 

brown,  732 

carbohydrate,  732 

character  of,  4() 

composition  of,  47 

curds  in.  47,  50,  731 

in  digestive  diseases,  731 

fat  in,  4t) 

fatty,  731 

green,  732 

in  lu-alth,  4t) 

incontinence  of,  815 

microchemical  examination  of,  732 

nuicous,  731 

number  of  daily  evacuations,  47 

protein,  731 

teaching  control  of  evacuations,  77 


868 


INDEX 


Fede's     disease,     665.     See     Sublingual 

fibroma. 
Feeding,  artificial,  108.     See  also  Foods, 
Diet,  Milk,  etc. 

articles  of  food  forbidden,  173 
permitted,  172 

Baner's  formulae,  138 

breast-,  82.     See  Breast-feed i7ig. 

buttermilk,  147 

calculation  of  formulae,  137 

caloric  method,  121 

casein  milk,  148 

in  chronic  indigestion,  180 

in  colic,  179 

in  constipation,  179,  760 

details  for  modification  of  milk,  123 

in  diarrhea,  179 

equation  for  obtaining  percentage.s,  140 

from  twelve  to  eighteen  months,  169 

from  eighteen  to  twentv-four  months, 
170 

from  two  to  three  years,  171 

from  three  to  six  years,  172 

gavage,  247 

general  rules  for  calculation  of  formulae, 
142 

home  modification,  134 

in  first  year,  168 

in  second  year,  169 

three  to  six  years,  172 

foods  permitted,  172 

to  be  used  cautiously,  173 
to  be  avoided,  173 

imperfect  feeding  as  cause  of  disease, 
182 

intervals  for,  133 

laboratory  modification,  134 

lactic  acid  milk,  147 

mixed,  88 

nasal,  248 

pasteurization  of  milk,  125 

peptonized  milk,  146 

percentage-,  120 

preparing  food,  136 

quantity  of  fat  required,  132 

selection  of  percentages,  132 

skimmed  milk  mixtures,  139 

in  sickness,  178 

sterilization  of  milk,  125 

supplemental,  88 

top-milk  mixtures,  139 

in  vomiting,  178 

whey,  145 

whey-cream  mixtures,  145 

whole-milk  mixtures,  139 
Feer's  milk  preparation,  159 
Ferments,  cow's  milk,  112 

effect  of  heat  on,  110 

in  human  milk,  98 
Fetal  circulation,  54 

changes  in,  after  birth,  55 
Fever,  transitory,  in  newborn,  302 
Finkelstein's  classification  of  alimentary 

diseases,  697 
Fissure  of  anus,  814 
Fistula  in  ano,  815 

in  trachea,  692.     See   Tracheo-esopha- 
geal  fistula. 


Flour-ball,  157 

Fluid  ounce,  equivalents  of,  219 

Fluidrachm,  equivalents  of,  219 

Follicular  enteritis,  747.     See  Ileocolitis. 

Fomentations,  244 

Fontanelles  in  rickets,  591 

size  and  time  of  closing  of,  33,  34 
Food.     See   also  Diet,  Feeding,  Artificial 
feeding.  Milk,  etc. 
absorption  of,  45,  48 
action  of  different  elements,  48,  99,  127 
carbohydrate  of,  49,  99 
fat  of,  48,  95,  99,  128 
length  of  time  in  stomach,  44 
metabolism  of,  48 
protein  of,  50,  51,  96,  99,  130 
relationship  to   constipation,    758 
to  diarrhea,  734,  736,  738 
to  infantile  atrophy,  611 
to  chronic  intestinal  indigestion,  763, 
771 
salts  of,  51,  97,  100,  132,  175 
Food-intoxication,  738 
Foods.     See  also  Feeding,  Artificial  feed- 
ing, and  Diet. 
amount  of  food-elements  required  after 

first  year,  173 
amylaceous,  152 
to  be  avoided  from  three  to  sLx  j-ears, 

173 
caloric  value,  various,  174 
calories  required  after  first  year,  173 
carbohydrate,  152 

table    of    weights   of   carbohydrate 
foods,  153 
commercial,  160 
percentage  composition  various  foods, 

174 
permitted  from  three  to  six  years,  172 
proprietary,  160 
amylaceous,  163 
condensed  milk,  161 
dextrinized  foods,  163 
dried  milk,  161 
malted  foods,  163 
miscellaneous,  165 
nitrogenous,  165 
protein,  165 
causing  rickets,  584 
causing  scurvy,  603 
starchy,  152 

to  be  used  cautiously  from  three  to  six 
years,  172 
Foreign  bodies  in  esophagus,  695 
in  intestine,  817 
in  stomach,  717 
lorsan,  167 
Fourth  disease,  363 
Fractures  in  rickets,  594 
Freeman  pasteurizer,  126 
Friction,  239 
Friedenthal's  milk,  160 
Fruits,  caloric  values  of,  176 
in  constipation,  760 
for  infants  and  children,  170,  173 
in  scorbutus,  610 
Fungus  of  umbilicus,  287 
Funnel-chest,  689 


INDEX 


869 


Gaeutxer's  mother-milk,  158 
Gait.     See  Walking. 

Gall-bladder  and  ducts,  disease  of,  843. 
See  also  Congenital  obliteration  of  bile 
ducts. 
Gangrene  of  appendix,  803 
in  diabetes,  639 
in  diphtheria,  455 
in  hernia,  795 
in  intussusception,  786 
in  measles,  350 
of  mouth,  659 
of  navel,  289 

in  recurrent  vomiting,  703 
in  scarlatina,  328 
in  stomatitis,  659 

in  ulceromembranous  tonsillitis,  682 
Gangrenous  appendicitis,  803 
stomatitis,  659 
varicella,  388 
Gargles,  237 

( Jases  of  digestive  tract,  46 
Gastralgia,  704 

(iastric  hemorrhage,  264,  266,  716.     See 
also  Melena  and  Hemorrhagic  diseases 
of  newborn. 
indigestion,  acute,  719 
chronic,  723 
in  infancy,  724 
in  older  children,  724 
Gastritis,  acute,  721 
catarrhal,  721 
chronic,  723 
corrosive,  722 
pseudomembranous,  722 
Gastro-duodenitis,  833 
Gastro-enteric  intoxication,  acute,  738 
acidosis  in,  741 
acute  milk-poisoning,  741 
alimentary  intoxication,  741 
cholera  infantum,  741 
choleriform  diarrhea,  741 
complications  and  sequels,  742 
diagnosis,  743 

without  fever  or  diarrhea,  741 
etiology,  738 
forms  of,  740 

influence  of  hot  weather,  738 
ordinary  form,  740 
pathological  anatomy,  739 
relapse  in,  741 
relationship  of  bacteria,  739 
treatment,  743 
Gastro-enteritis,  acute,  738.     See  Claslro- 

enteric  intoxication,  acute. 
Gavage,  247 

Genital  organs,  care  of,  71 
Genito-urinary  system  in  early  life,  59 
tract,   tuberculosis  of,   557.     See  also 
Kidney. 
Geographical  tongue,  667 
German  measles,  356 
Glands,       lymphatic.     See       Lymphatic 
glands. 
salivary,  40,  43.  668 
Glass  graduate,  136 
Glossitis,  667 
Gonococcir  peritonitis.  849 


Gonorrheal  ophthalmia,  297 

stomatitis,  663 
Grippe,  472.     See  also  Influenza. 
adenitis,  478 
bacteria  of,  473 
compUcations  and  sequels,  478 
cutaneous  eruption  in,  479 
diagnosis,  480 
etiology,  473 
febrile  form,  477 
history,  472 
mortality  from,  480 
nephritis  in,  478 
otitis  in,  478 
pneumonia  in,  478 
prognosis,  480 
symptoms,  474 
treatment,  481 
varieties  of,  476 
Growth.     See  also  Weight  and  Length. 
of  chest,  35 

conditions  influencing,  20,  25 
of  head,  32 

influence  of  sex  on,  20,  et  seq. 
relation  of  head  and  chest,  36 
relation  of  head,  trunk  and  extremities. 

31 
Growths,  morbid,  of  intestine,  818 

of  liver,  842 

of  mouth,  665,  668 

of  pancreas,  844 

of  peritoneum,  859 

of  pharj^nx,  670 

of  stomach,  718 

of  tonsils,  679 
Ciums,  abscess  of,  651 

bleeding  from,  in  scorbutus,  607 
inflammation  of,   652.     See   Catarrhal 

slojnatitis. 
lancing  of,  651 
in  newborn,  37 
in  scorbutus,  606 
in  ulcerative  stomatitis,  657 
symptoms  connected  with,  198 
Gymnastic  exercises,  249 

Habit  spasm,  influence  of  dental  caries  in 
producing,  652 

vomiting,  700 
Hair  in  infancy,  34 
Hair-ball  in  stomach,  718 
Hare  lip,  648 
Head,  circumference  of,  32.  33 

closing  of  fontanelle,  33,  34  | 

hair,  34 

relation  to  size  of  thorax,  36 
to  trunk  and  extremities,  31 

in  rickets,  591 

size  and  shape.  32,  33 

symptoms  coiuiected  with,  197 

washing  of,  6S,  70 
Head-bangiiig,  2Sr) 
Head-nodding,  2St) 
Head-rolling,  2S6 
Hearing,  development  of,  66 
Heart,  apex-beat,  55 

auscultation  of,  55 

circulation  in.  at  birth,  54 


870 


INDEX 


Heart  in  diphtheria,  453 

foramen  ovale,  54 

in  measles,  349 

normal,  in  early  lif(\  54 

percussion  of,  55 

position  of,  55 

in  scarlet  fever,  327 

size  of.  in  early  life,  54 

sounds  of,  in  infancv,  55 
Heat,  dry,  245 
Height,  27.     See  Length. 
Hematemesis,  26S.  716 
Hematoma  of  scalp,  269 

of  sternocleidomastoid,  272 
Hematuria  in  scorbutus,  608 
Hemoglobinuria,  acute  infectious,  of  new- 
born, 262 
Hemolytic  icterus,  835 
Hemoptysis,  552,  559 
Hemorrhage  in  cerebral  paralysis,  265 

cause  of  sudden  death,  218 

gastric,    716.     See    also    Melena    and 
Hemorrhagic  disea.^es   of  newborn. 

intestinal,  799 

in  newborn,  263 

in  pertussis,  484,  488 

in  scorbutus,  604 

from  stomach,  716 

in  syphilis,  571 

in  typhoid  fever,  406 

from  umbilicus,  292 
Hemorrhagic  disease  of  newborn,  264 

measles,  348 

typhoid  fever,  406 

variola,  370 
Hemorrhoids,  816 
Hepatitis,  suppurative,  842 
Hereditv,  influence  of,  in  earlj'  life,  182 
Hernia,  "790 

acquired,  792 

congenital,  791,  794,  796 

into  cord,  791 

diaphragmatic,  796 

inguinal,  varieties  of,  794 

Meckel's  diverticulum,  810 

umbilical,  791 

ventral,  796 
Hesse- Pfund's  infant-food,  159 
History,  obtaining  of,  183 
Home    modification   of   milk,    134.     See 

also  Milk,  cow'a. 
Homogenized  milk,  159 
Hook-worm,  828 
Hoos'  albumin-milk,  168 
Hutchinson's  teeth,  576 
Hydatids  of  liver,  843 
Hydrocephalus  in  cerebrospinal  fever,  428 
Hydrotherapy,  239 
Hygiamaf  167 

Hygiene,  68.     See  also  Bathing,  Clothing, 
etc. 

of  newborn,  68 

of  nursing  mother,  84 

prenatal,  68 
Hygroma  cysticum,  691 
Hyperesthesia  in  cerebrospinal  fever,  420 

in  poliomyelitis,  523 
Hyperpnea  in  acidosis,  636 


Hypertonia,  muscular,  613.  617 
Hypodermic  medication,  231 
Hypodermoclysis,  231 

Ice-bag,  244 
Icterus,  acholuric,  835 
catarrhal,  833 

congenital  and  familial,  836 
in  congenital  obliteration  of  bile-ducts, 

273 
in  congestion  of  liver,  833 
familial,  836 
gravis,  835 
hemolytic,  835 
idiopathic,  273 
infectious,  835 
of  newborn,  272,  274 
from  other  causes,  837 
in  sepsis  neonatorum,  259 
svmptomatic,  272 
varieties  of,  272,  833 
Idiopathic  icterus,  272 
Idiosyncrasy  to  proteins,  131 
Ileocolitis,  acute,  747 
amebic,  748 
catarrhal,  751 
chronic,  755 

complications  and  sequels,  752 
course  and  prognosis,  751 
diagnosis,  752 
etiology,  747 
follicular,  751 
membranous,  749 
pneumonia  complicating,  752 
treatment,  753 
Ileum,  congenital  stenosis  or  atresia,  781 
Inanition,  acute,  616 
Incontinence  of  feces,  815 
Incubators,  255 

Indicanuria  in  constipation,  759 
Indigestion,  acute  gastric,  719 
intestinal,  736 
symptoms,  736 
treatment,  737 
bilious,  832 
chronic  gastric,  723 
symptoms,  724 
treatment,  725 
intestinal,  763,  771 
diagnosis,  766,  773 
in  infants,  763 
in  older  children,  771 
symptoms,  764,  771 
treatment,  767,  774 
Infancy,      18.     See     also      Development, 

Hygiene,  etc. 
Infant,  newborn,  18,  19 

premature,  252.    See  Premature  infants. 
Infant-feeding.     See  Feeding. 
Infant-foods.     See  Foods. 
Infantile  typhoid  fever,  401 
Infantilism,  intestinal,  773 
Infectious  diseases,  305 
definition,  305 
disinfection,  308 
dissemination,  306 
general  rules  for  care  of,  306 
quarantine,  300,  307,  308 


INDEX 


871 


Infectious  diseases,  erythema,  363 

hemolytic  icterus,  835 
Influenza,  472.     See  also  Grippe. 
Inhalations,  235 
Inheritance,    influence   of,   in   earlv   life, 

182 
Injections,  hypodermic,  231 
of  intestine,  233,  235 
intraperitoneal,  232 
intravenous,  245 
Injuries  caused  bv  protein,  131 

by  starch,  616,  764,  771 
Insufflation,  238 
Intestinal  colic,  728 
hemorrhage,  799 
indigestion,  acute,  736 
chronic,  763 
in  infants,  763 

treatment,  767 
in  older  children,  771 
treatment,  774 
infantilism,  773 
obstruction,  781 
acquired,  783 
parasites,  818 
ulceration,  796 
Intestines,  bacteria  of,  45 
development  of,  42 
digestion  in,  44 
dilatation  of,  777 
diseases  of,  696,  728 
enteroclysis,  235 
foreign  bodies  in,  817 
hemorrhage  in,  264,  268,  799 
hernia  of,  790 
in  infancy,  42 

inflammation  of,  747.     See  Ileocolitis. 
injection  of,  233-235 
intussusception  of,  784 
irrigation  of,  233 
length  of,  42 

malformations  of,  781,  783 
morbid  growths  of,  818 
obstruction  of,  781 
parasites  of,  818 
perforation  of,  407 
stenosis  of,  781 

strangulation  of,  by  Meckel's  diverticu- 
lum, 783,  810 
tuberculosis  of,  557,  798 
ulceration  of,  796 
in  ileocolitis,  741) 
in  typhoid  fever,  393 
Intoxication,  alimentary,  698,  741 
acute  gastro-enteric,  738 
acidosis  in,  741 
choleriform  diarrhea,  741 
cholera  infantum,  741 
classification,  740 
complications       and       seciucls, 

742 
diagnosis,  743 
ordinary  type,  740 
•     pathological  anatomy,  739 
sclerema  in,  742 
treatment,  743 
without  diarrhea,  741 
Intraperitoneal  injections,  232 


Intra -uterine  life,  17 

characteristics  of,  at  different  periods, 
252 
Intravenous  injections,  245 
Intubation  in  diphtheria,  466 

in  pertussis,  493 

in  subglottic  laryngitis,  404 
Intussusception,  784 

agonal,  785 

diagnosis,  789 

etiology,  784 

pathological  anatomy,  785 

symptoms,  787 

treatment,  790 

varieties  of,  786 
Inunctions,  237 
Iodides  in  breast-milk,  106 

dose  of,  231 
Ipecacuanha,  226 
Iron,  226 

Iritis,  sj'philitic,  577 
Irrigation  of  intestine,  233,  235.     See  also 

Enemata. 
Ischiorectal  abscess,  815 

Jaundice.     See  Icterus. 
Jaws,  abscess  of,  648,  651 

exostoses,  648 

morbid  growths  of,  648 

necrosis,  648,  660 

in  newborn,  34 

prognathism,  648 

in  gangrenous  stomatitis,  660 

in  ulcerative  stomatitis,  657 
Jejunum,  stenosis  of,  782 
Joints  in  rheumatism,  622,  623 

in  scarlet  fever,  325 

in  sepsis  in  newborn,  259 

syphilis  of,  571,  575 

Kernig's  sign,  420 
Keratitis  in  syphilis,  577 
Kidneys  at  birth,  59 

syphilis  of,  573 

tuberculosis  of,  557 
Knee-jerk.     See  also  Reflexes. 

in  diphtheria,  454 

in  poliomyelitis,  524 
Knee,  knock-,  in  rickets,  594 
Koplik  spots  in  measles,  340 
Kyphosis  in  rickets,  593 

Laboratory  modification,  134 
Lachrymal  glands  in  mumps,  500 
Lactation,    82,    92.     See   Breast  feeding. 

Human  milk. 
Lactic  acid  milk,  147 
Landry's  paralysis,  529 
Larosan,  168 

Laryngismus    stridulus.     See    also    Lar- 
yyigospasm. 

relation  to  rickets,  597 
Laryngeal    diphtheria,    449.     See    Diph- 
theria. 

antitoxin  for,  463 

operative  treatment  for,  466 

jjrognosis  in,  45() 


872 


INDEX 


Laryngospasm.     See  Laryngismus  strid- 
ulus. 
influence  in  causing  sudden  death,  217 
in  lymphatism,  634 
in  pertussis,  485 
Larj'nx  in  infanc)-,  53 
Late  rickets,  598 
Lavage  of  stomach,  246 
Lehndorf  and  Zak's  food,  159 
Length  at  birth,  28 
in  first  j'ear,  29,  30 
from  one  to  five  years,  30 
from  five  to  sixteen  years,  31 
relation  of  head,  trunk  and  extremities, 

31 
influence  of  season  on,  30 
influence  of  sex  on,  28-30 
Life,  divisions  of,  17 

intrauterine,  17 
Limbs,  19,  37.     See  Extremities. 
Lime-water,  109,  123,  124 
Lips,  diseases  of,  648 
erosions  at  angles,  649 
fissures  in  syphilis,  569 
hare-,  648 
perleche,  649 
Liver,  abscess  of,  842 
amyloid,  841 
acute  yellow  atrophy  of,  837 
congenital    obliteration    of    bile-ducts, 

273 
congenital  biliary  cirrhosis,  273 
biliousness,  832 
cirrhosis  of,  838 
diseases  of,  832 

functional,  832 
echinococcus  of,  843 
enlargement  of,  838 
fatty,  841 
hydatids,  843 
in  infancy,  41 
inflammation  of,  842 
morbid  growths  of,  842 
nut-meg,  840 
in  rickets,  590 
in  syphilis,  573 
tuberculosis  of,  547 
in  chronic  valvular  disease,  833 
Lock-jaw,  513.     See  Tetanus. 
Lung,  atelectasis,  284 
hemorrhage  into,  265 
in  infancy,  54 

physical  examination  of,  189,  190 
tuberculosis  of,  550,  et  seq. 
Lymphatic  diathesis,  632 
glands  in  diphtheria,  447 

frequency  of  involvement,  209 

in  measles,  344 

in    pseudomembranous  pharyngitis, 

675 
in  retropharyngeal  abscess,  676 
in  rickets,  597 
in  scarlet  fever,  316 
in  hereditary  syphilis,  571,  577 
in  tonsiUitis,  680,  682 
in  tuberculosis,   556.     See   Tubercu- 
losis and  Tuberculous  adenitis. 
in  typhoid  fever,  393 


Lympliatism,  632 
Lymphocytes  in  early  life,  69 
normal  excess,  in  infancy,  59 

Macroglossia,  664 
Malaria.  502 
chronic,  510 

complications  and  sequels,  510 
diagnosis,  511 
estivo-autumnal,  507 
etiology,  502 
irregular  forms,  508 
latent,  510 

malarial  cachexia,  510 
ordinary  forms,  504 
parasite  of,  503 
prognosis,  511 
quartan,  507 

quinine,  strength  of  different  prepara- 
tions for,  512 
recurrence,  510 
relapse,  510 
symptoms,  504 
tertian,  507 
transmission,  503 
treatment,  512 
tropical,  507 
Malformations,  congenital,  of  bile-ducts, 
273,  843 
of  colon,  777,  781 
of  esophagus,  691 
of  gall-bladder,  843 
general  considerations,  209 
in  congenital  hernia,  791,  794,  796 
of  jaws,  648 
of  lips,  648 

of  Meckel's  diverticulum,  295,  810 
of  pharynx  and  palate,  670 
of  rectum  and  anus,  783 
of  salivary  glands,  668 
of  small  intestine,  781 
of  stomach,  708,  718 
of  tongue,  664,  665 
Malnutrition,  615 
etiology,  615 

in  chronic  indigestion,  765 
prognosis,  617 
symptoms,  616 
treatment,  618 
Malpositions,  congenital,  of  stomach,  718 

of  teeth,  650 
Malt  extracts,  129 
--    strength  of,  129 
Maltose,  49,  129 
Malt-soup,  156 

Mammarjf  glands.     See  Breast. 
Mania  in  typhoid  fever,  408 
Marasmus,  610.     See  Atrophy,  infantile. 
Massage,  249 
{       in  chronic  intestinal  indigestion,  776 

in  constipation,  761 
1       in  malnutrition,  619,  620 
in  poliomyelitis,  537 
in  rachitis,  602 
j   Mastitis,  295 
j   Maternal  impressions,  182 
I   Measles,  336 

abortive  form,  346 


INDEX 


873 


Measles,  atypical  forms,  345 
blood  in,  344 

catarrhal  symptoms  of,  339,  341 
complications  and  sequels,  348 
desquamation,  344 
diagnosis,  352 
ears  in,  349 
ecchymotic,  348 
eruption,  buccal,  339 

cutaneous,  341,  345 

prodromal,  341 
diphtheria  in,  350 
etiology,  336 
eyes  in,  349 
facies  in,  343 

gastro-intestinal  symptoms  in,  349 
germ  of,  337 

German,  356.     See  also  Rubella. 
heart  in,  349 
hemorrhagic,  348 
incubation,  339,  345 
period  of  infectiousness,  338 
other     infectious     diseases     combined 

with,  350 
invasion,  339,  345 
kidneys  in,  349 
larynx  in,  348 
lesions  of,  338 
lungs  in,  349 
lymphatic  glands  in,  344 
malignant,  348 
mild,  345 
mortality,  351 
nervous  system  in,  350 
ordinary  type,  339 
otitis  in,  349 

pathological  anatomy,  338 
pseudomembranous     pharyngitis     in, 

349 
pneumonia  in,  349 
prognosis,  350 
prolonged  form,  347 
prophylaxis,  354 
quarantine,  354 
recurrence,  350 
relapse,  350 

respiratory  system  in,  339,  343,  348 
severe  form,  347 
susceptibility  to,  337 
symptoms,  339 
temperature  in,  341,  343,  344 
transmission,  338 
treatment,  354 
tuberculosis  after,  350 
typhoid  form,  348 
urine  in,  349 
Meat-broths,  151 
Meats,  caloric  vahie  of,  175,  177 

in   chronic   intestinal    indigestion, 

775 
in  illness,  180 

in  second  year  anfl  later,  170-173 
Mechanotherapy,  249 
Meckel's  diverticulum,  809 

hernia  of,  810 

inflammation  of,  810 

patulous  at  umbilicus,  810 

protruding,  295 


Meckel's  diverticulum,  strangulation  o' 
intestine  bj^,  783,  810 
volvulus,  810 
Meconium,  46 
Medicines.     See  Drugs. 
Megacolon,  777 
Meig's  gelatine  food,  158 
Melena,  266 
Meningitis,       cerebrospinal,       415.     See 

Cerebrospinal  fever. 
Meningo-encephalo-myelitis,     517.      See 

Poliomyelitis. 
Menstruation,  time  of  normal  develop- 
ment, 19 
Mental  affections,  symptoms  connected 
with,  207 
powers,  development  of,  65 
Mercury,  226 
Merycismus,  717 

Mesenteric  glands,  tuberculous,  556 
Metabolism,  basal,  52 
energy,  52 
of  food,  48 
gaseous,  52 
Metric     system,     employment    of.     See 

Preface. 
Micrognathia,  648 
Micturition,  frequency  of,  61 
Mikulicz's  disease,  669 
Milk,  albumin-,  148 
casein,  148 

cow's,  108.     See  also  Diet,  Foods  and 
Artificial  feeding. 
action  of  different  food-elements  in, 

127 
bacteria  in,  113 

removal  of,  125 
bottom  milk,  117 
caloric  value,  110 
carbohydrate,  128 
certified,  118 
characteristics  of,  109 
effect  of  cold  on,  110 
comparison  with  human,  1 19 
composition  of,  111 
condensed    milk,    161.     See    Foods, 

proprietary. 
cream  of,  115 

preventing  formation  of  curds,  124 
dairy  methods,  118 
dried,   161.     See  Foods,  proprietary. 
elements  altering  proportions  of,  124 
examination  of,  110 
fat  of,  111,  128 
normal  variations  of  fat.  111 
ferments,  112 
effect  of  heat  on,  109,  125 
mineral  matter,  112,  132 
formulae  for  mixtures,  137,  139 
modification  of,  119,  123,  124 
home,  134 
laboratory,  134 
pasteurizing,  125,  126 
peptonizing,  146 
percentage-strengths     of      different 

lavers  of  milk,  139 
protein  of,  112,  130 

normal  variations  of,  112 


874 


INDEX 


Milk,  cow's,  pus  in,  114 
altering  reaction,  128 
requirements  of  good,  117 
salts,  112,  132 

normal  variations  of,  112 
skimmed,  117 
starch,  130 
sterilizing,  125 
sugar.  111,  128 

normal  variations  of.  111,  112 
top-,  115,  139 

variations  in  different  breeds.  111 
earlv  secretion  of,  in  infants,  60 
goat's,  109 
human,  92 

action  of  difTerent  constituents,  99 

bacteria  in,  100 

caloric  value,  99 

colostrum,  93 

composition  of,  94 

conditions  altering  character,  103 

different  constituents,  95 

influence  of  diet,  105 

examination  of,  101 

influence  of  exercise  on,  105 

fat  in,  95,  99 

ferments  of,  98 

influence  of  illness,  105 

of  intervals  of  nursing,  104 
of  menstruation,  104 
effect    of    mental    and    nervous    in- 
fluences, 105 
mineral  matter  of,  97,  100 
modifying  of,  106 
influence  of  number  of  pregnancies, 

104 
passing  of  drugs  into,  106 
influence     of    period    of    lactation, 

103 
characteristics  of  poor,  100 
effect  of  poor,  on  infant,  100 

of  pregnancy,  104 
protective  bodies,  98 
protein  of,  96,  99 
quantity  secreted,  92 
reaction,  94 
salts  of,  97,  100 
specific  gravity,  94 
sugar  of,  96,  99 
water  of,  95,  99 
various  mammalian,  108 
Milk-laboratories,  134 
Milk-poisoning,  741 
Milk-sugar  in  artificial  feeding,  128 
measuring  of,  135 
percentage,  in  cow's  milk.  111,  140 

in  human  milk,  96 
quantities  to  be  added  to  mixtures,  142 
Mind,    significance    of    symptoms    con- 
nected with,  207 
Mineral  matter.     See  Salts. 

springs,  243 
Modified  milk.     See  Milk,  cow's. 
Monoplegia,  in  poliomyelitis,  526 
Monti's  whey-milk,  159 
Morbid  growths.     See  Growths,  morbid. 
Morbidity  at  different  ages,  209 
M(jrphine.     See  Opiates. 


Mortality,  at  different  ages,  211-218 

diminution  of,  214 

fetal,  210 

in  first  year.  111 
Mosquera's  beef-jelly,  167 
Mouth,  bacteria  of,  45 

care  of,  in  infancy,  70 

diseases  of,  648 

erosions  at  angles  of,  649 

in  infancy,  37 

malformations  of.     See  Jaws,  Lips,  etc. 

perleche,  649 

significance    of    svmptoms    connected 
_  with,  198 

simple  ulceration  of,  663 
Mouth-breathing,  from  adenoids,  687 

in   retropharyngeal   abscess,    677 

in  syphilis,  571 
Movements  of  bodv,   resisted,  in  treat- 
ment, 249 
significance  of  symptoms  connected 
with,  194 
Mucous  disease,  772 
Mumps,  494 

blood  in,  499 

complications  and  sequels,  499 

diagnosis,  501 

ears  in,  500 

etiology,  495 

lachrymal  glands  in,  500 

nervous  disturbances  in,  500 

orchitis  in,  499 

other  infectious  diseases  with,  500 

pathological  anatom.y,  496 

prognosis,  501 

symptoms,  496 

treatment,  501 
Muscles,  hypertonia,  613,  617 
Muscular   atrophy  in   poliomyelitis,  527 

power,  development  of,  64 
Mustard  applications,  238 

bath,  242 
Myalgia,  626 
Myocarditis,  in  diphtheria,  453 

in  scarlet  fever,  327 

Nails  at  birth,  19 
care  of,  70 

in  hereditary  syphilis,  569 
in  premature  infants,  253 
Nasal  diphtheria,  449 

feeding,  248 
Nasopharyngeal  diphtheria,  449 
Navel,  diseases  of,  286.     See  also  Umbili- 
cus. 
Nephritis,  acute  diffuse,  in  diphtheria,  454 
chronic  diffuse,  in  scarlet  fever,  326 
in  scarlet  fever,  325 
Nervous  conditions,   influence  on  secre- 
tion of  milk,  105 
diarrhea,  735 

functions,  development  of,  64 
symptoms,  in  measles,  350 
in  nuimps,  500 
in  pertussis,  488 
in  scarlet  fever,  328 
in  tuberculosis,  558 
in  typhoid  fever,  400 


INDEX 


\io 


Nervous  system,    significance   of  symp- 
toms connected  with,  207 

vomiting,  700 
Neuritis  in  diphtheria,  454 
Newborn.  IS 

asphyxia,  276 

asthenia  of.  286 

atelectasis  of.  284 

bile-ducts,   obliteration  of,   273 

blood  in,  58 

care  of.  68 

cephalhematoma,  269 

characteristics  of,  19 

diseases  of.  251 

edema  of,  301 

acute  fatty  degeneration  of,  260 

fever,  in  transitory,  302 

hematoma     of      sternocleidomastoid, 
269 

hemoglobinuria,  acute  infectious,  262 

hemorrhage  in.  263 

hemorrhagic  disease  of,  264 

icterus  in,  272,  274 
.   infection  of.  258 

malformations  in.     See  Malformations. 

mastitis  in,  295 

melena,  266 

morbidity  of,  209 

ophthalmia  of,  296 

protruding  Meckel's  diverticulum,  295 

sclerema  of,  299 

scleroderma  in,  300 

sepsis  in,  258 

umbilicus,  diseases  of,  286.     See  also 
Umbilicus.,  diseases  of. 
Night-clothing,  72,  74 
Nigrities    linguae,    666.     See   also    Black 

tongue. 
Nipples,  mother's,  depressed,  83 

hemorrhage  from,  a  cause  of  melena, 

267 
hygiene  of,  83,  84 

rubiaer,  135 
care  of,  137 
Nitroglycerine,  226 

Noma   of    mouth,    659.     See    also   Gan- 
grenous stomatitis. 
Nose,  alteration  in  shape  from  adenoids, 
687 

applications  to,  237 

diphtheria  of,  449 

in  infancy,  53 

in  newborn,  34 

obstruction  of,  by  adenoids,  687 

saddle-no.se,  572,  575 

in  scarlet  fever,  323 

in  syphilis,  566,  572,  575 
Nurse-maids,  80 
Nurses,  trained,  80 

wet-,  90.     See  also  Wet-nurse. 
Nursery,  air-space  required  for,  79 

day-.  7S 

furnishings  of,  79 

heating  of,  79 

in  illness,  80,  307 

night-,  80 

l)osition  in  house,  79 

sick-room.  80.  307 


Nursing.     See  also  Breast-feeding. 

hygiene  of  mother,  84 

general  rules  for,  84 

intervals  of,  85 

preparation  for,  83 

wet-,  90 
Nursing-bottles,  135 

care  of,  137 
Nurslings,  18 
Nutrition  disorders,  583 
Nutrose,  167 

Oatmeal- WATER,  155 
Oil-enemata,  233 

in  chronic  constipation,  761 
intestinal  indigestion,  776 
Omphalitis,  288 
Omphalomesenteric  duct,  295 
Omphalorrhagia,  292 
Ophthalmia  neonatorum,  296 
Opisthotonos  in  cerebrospinal  fever,  420 

in  muscular  hypertonia,  613,  617 

in  tetanus,  5l5 
Opiates  in  diarrheal  disorders,  735,  738, 
745,  746,  754 

dosage  of,  227,  230 

passage  into  breast-milk,  106 

in  recurrent  vomiting,  704 

susceptibility  to,  226 
Optic  neuritis  in  cerebrospinal  fever,  427 
Orange-juice,  170 

in  scorbutus,  610 
Orchitis  in  mumps,  499 
Orthopnea  in  diphtheritic  laryngitis,  450 
Otitis  in  cerebrospinal  fever,  427 

in  diphtheria,  455 

in  grippe,  478 

in  measles,  349 

in  scarlet  fever,  323 

in  syphilis,  573,  577 
Oxyuris  vermicularis,  820 

Pack,  cold,  442 

hot,  242 

mustard,  242 

wet,  241 
Palate,  cleft,  670 

deformities  of,  670 

in  diphtheria,  454 

high  arch  of,  670 

from  adenoid  growths,  688 

morbid  growths  of,  670 

paralysis  of,  454,  671 

ulceration  of,  664.     See  also  Bcdnar's 
aphthae. 

in  syphilis,  575 
Pancreas,  diseases  of,  844 

in  infancy,  42 

inflammation  of,  844 

in  mumps,  500 

pancreatitis,  844 

in  syphilis,  577,  844 
Paralysis,  acute  infantile,  525.     S<'(>  f'ulin- 
m//(7///.N-. 

in  cer(>l)r()spinal  fever,  428 

in  diphtheria,  454 

infantile    spinal,    525.     See    I'oliomi/c- 
liti.s. 


876 


INDEX 


Parasites,  intestinal,  818 
Paratyphoid  fever,  415 
Parotitis,"epidemic,  495.    See  also  Mum-ps. 

secondary,  669 
Pasteurized  milk,  125,  126 
Patented  foods,  160 
Peliosis  rheumatica,  859 
Pellagra,  643     . 
etiolog}',  643 
symptoms,  645 
treatment,  647 
Pelvis  in  infancy,  37 
Peptonized  milk,  146 
Peptonoids,  drj-.  167 
Perambulator,  77 

Percentage  composition  of  various  foods, 
174 
method    of    feeding,     120.     See    also 
Feeding. 
Percentages  to  calculate  amount  present 
in  food,  143 
calculation  to  produce  desired  formula, 

137 
selection  of,  132 
Pericarditis  in  rhuematism,  625 
Periomphalitis,  288 
Peritoneum,  diseases  of,  845 

tumors  of,  859 
Peritonitis,  acute,  845 
diagnosis,  849 
etiology,  845 

pathological  anatomy,  846 
prognosis,  847 
symptoms,  846 
treatment,  850 
in  appendicitis,  806 
chronic  ascitic,  851 

non-tuberculous,  851 
in  diverticulitis,  811 
general,  846 
gonococcic,  849 
in  infancj^,  847 
in  intussusception,  788 
localized,  847 
in  newborn,  259 
pneumococcic,  848 
streptococcic,  848 
tuberculous,  558,  852 
ascitic  form,  854 
caseous  form,  854 
diagnosis,  858 
etiology,  852 
fibrous  form,  854 
pathological  anatomy,  853 
prognosis,  856 
symptoms,  853 
treatment,  858 
Peritonsillitis,  683 
Perleche,  649 
Pertussis,  482 
bacteria  of,  483 
blood  in,  486 
catarrhal  stage,  485 
circulatory  disturbance,  488 
complications  and  sequels. ^487 
convulsions  in,  488 
decline,  487 
diagnosis,  490 


Pertussis,  digestive  disturbances,  487 
etiology,  482 
heart  in,  488 
hemorrhage  in,  488 
incubation  of,  485 
mortality  from,  489 
nature  of  disease,  483 
nervous  symptoms  in,  488 
paralysis  in,  488 
paroxysmal  stage,  485 
pneumonia  in,  487 
predisposing  causes,  482 
prognosis,  489 
prophylaxis,  491 
relapse  and  recurrence,  488 
respiratory  disturbances,  487 
symptoms,  485 
transmission,  484 
treatment,  491 
vomiting  in,  487 
Petticoat,  72 

Pharyngitis,  acute  catarrhal,  671 
chronic,  673 
pseudodiphtheritic,  674 
pseudomembranous,  674 
Pharynx,  adenoid  vegetations  of,  686 
deformities  of,  670 
diseases  of,  670 
diphtheria  of,  447,  449 
examination  of,  187 
inflammation  of.     See  Pharyngitis. 
morbid  growths  of,  670 
retropharyngeal  abscess,  676 
in  syphilis,  571,  577 
Phlebitis  of  umbilicus,  290 
Phthisis,  556 

Physical  examination,  183 
Physiology  in  early  life,  17 
Pin-worms,  820 
Plasmon,  167 
Pleurisy,  tuberculous,  558 
Pneumococcic  peritonitis,  848 
Pneumonia  in  diphtheria,  453 
in  gastro-enteric  infection,  742 
in  grippe,  478 
in  infantile  atrophy,  613 
in  measles,  349 
in  pertussis,  487 
in  rachitis,  597 
in  scarlet  fever,  327 
tuberculous,  550,  553 
in  typhoid  fever,  404 
Poliomyelitis,  acute,  517 
abortive  form,  532 
ataxic  form,  530 
atrophic  stage,  527 
bulbar  form,  530 
diagnosis,  534 
encephalitic,  acute,  530 
etiology,  518 
history,  517 
invasion,  523 
meningitic  form,  531 
micro-organisms  of,  520 
mortality,  533 

paralysis,  distribution  of,  526 
Landry's,  529 
recovery  from,  534 


INDEX 


877 


Poliomyelitis,  acute,  paralytic  stage,  525 
pathological  anatomy,  522 
polyneuritic  form,  531 
pontine  form,  530 
prognosis,  533 
progressive  form,  acute,  529 
relapse  and  recurrence,  533 
retrogression,  527 
spinal  fluid,  525 

form,  523 
stationary  stage,  527 
symptoms,  523 
transmission,  521 
treatment,  536 
Polypi,  rectal,  818 

Position  of  body,  significance  of,  194 
Poultices,  244 

Pregnancy,    character    of    milk    during, 
104 
hygiene  of,  83 

making  weaning  advisable,  86 
Premature  birth,  death  from,  211 
infants,     character     of,     at     different 
periods  of  intra-uterine  life,  252 
feeding  of,  256 
management  of,  255,  256 
symptoms,  253 
viability  of,  254,  255 
Proctitis,  813 
Profeta's  law,  580 
Prognathism,  648 
Prolapsus  ani,  811 

Proprietary  foods,  160.     See  Foods,  pro- 
prietary. 
Protein,    action    of,     in     food,    50,    99, 
130 
amount  needed  bv  infants,  130 
in  cow's  milk,  112,  130 
deleterious  effect  of  excess,  131 
function  of,  in  food,  50,  99,  130 
in  human  milk,  96,  99 
injury  by,  50,  51,  131 
selection  of  percentages  of,  132 
Protein-indigestion,  51,  131 
Protein-mUk,  148 
Pruritis  ani,  816 
Pseudodiphtheria.     See  Pharyngitis. 

bacillus,  445 
Pseudoparalysis,  in  rickets,  596 
in  scurvy,  606 
syphilitic,  571 
Psychotherapy,  248 
Pterygoid  ulcer,  664.     See  also  Bednar's 

aphthae. 
Puberty,  19 
Pulse,  indications  derived  from,  201 

in  typhoid  fever,  399 
Pulse-respiration  ratio,  200 
Pulse-temperature  ratio,  201 
Purgative  drugs,  228 
Purpura  variolosa,  370 
Pylorospasm,  707 
Pylorus,  stenosis  of,  707 
diagnosis,  712 
etiology,  708 
progno.sis,  711 
symptoms,  709 
treatment.  712 


Quarantine,  general  considerat'on,  306- 
308 
in  diphtheria,  461 
in  measles,  354 
in  scarlet  fever,  332 
Quinine,  228 

strength    of     different     preparations, 
512 
Quinsy,  683 

Rachitis.  583 
acute,  598,  602 
circulatory  system  in,  597 
complications  and  sequels,  599 
congenital,  598 
convulsions  in,  599 
course  and  prognosis,  599 
diagnosis,  599 
digestive  system  in,  597 
etiology,  583 
extremities,  594 
fetal,  598 
frequency  of,  583 
general  condition,  596 
head  in,  591 
late,  598 

nervous  sj^stem  in,  597 
pathological  anatomy,  586 
pathogenesis,  585 
respiratory  system  in,  597 
spine  in,  593 
symptoms,  590 
thorax,  592 
treatment,  600 

of  deformities,  602 
Radioscopy,  193.     See  also  X-ray. 
Radiotherapy,  250 
Ranula,  668 
Reaction  of  degeneration  in  poliomj-elitis, 

528 
Rectal  polypus,  818 
Rectum,  abscess  of,  815 
diseases  of,  811 
feeding  by,  233 
hemorrhage  from,  in  diverticulitis,  811 

in  fissure  of  anus,  815 

in  gastric  ulcer,  717 

in  ileocolitis,  750 

in  intestinal  ulceration,  797 

in  intussusception,  787 

in  melena,  267 

in  proctitis,  814 

in  rectal  polypus,  818 

in  scorbutus,  604 

in  typhoid  fever,  406 
hemorrhoids,  816 
malformations  of,  783 
medication  by,  233 
prolapse  of,  811.     See  also  Prolapsus 

ani. 
pruritus,  816 

congenital  stenosis  and  atresia,  783 
Recurrent  vomiting,  701 
Reflexes,    ankle  clonus.     See    Ankle    clo- 

71  us. 

development  of,  65 
Kornig,  420 
•  {•■gurnitation.     See  Vomiting. 


878 


INDEX 


Respiration.     See     also     Dyspnea     and 
Orthopnea. 

artificial,  280 

in  cerebrospinal  fever,  422 

in  racl'.itis,  597 

rate  of,  54 

symptoms  connected  with,  200 
Rest  in  treatment,  250 
Retropharyngeal  abscess,  676.     See  also 

Abscess. 
Rheumatism,  620 

acute  articular,  622 

cardiac,  622,  625 

chorea  as  manifestation  of,  622,  625 

chronic  articular,  623 

cutaneous  manifestation,  626 

diagnosis,  627 

erythema  in,  626 

etiology,  620 

muscular,  626 

pathological  anatomy,  621 

prognosis,  627.     See  also  Endocarditis. 

purpura  in,  626 

recurrence,  627 

relapse,  627 

scarlatinal,  325 

subcutaneous  fibrous  nodules,  625 

S3^mptoms,  621 

tonsillitis  in,  626 

torticollis  in,  626 

treatment,  628 
Rhinitis,  syphilitic,  565,  571 
Rickets,  583.     See  also  Rachitis. 
Riga's  disease,  665.     See  also  Suhlingual 

fibroma. 
Roborat,  167 

Rotheln,  356.     See  Rubella. 
Rubella,  356 

complications,  361 

desquamation,  359 

diagnosis,  362 

eruption,  358 

etiology,  357 

incubation,  357 

invasion,  357 

Koplik  spots,  340 

h^mphatic  glands  in,  358 

morbilliforme,  359 

mouth  and  throat  in,  358 

ordinary  cour.se,  357 

prognosis,  361 

relap.se  and  recurrence,  361 

scarlatiniforme,  359 

symptoms,  357 

treatment,  362 
Rubeola,  336.     See  also  Measles. 

afebrilis,  345 

sine  catarrho,  346 

sine  eruptione,  346 
Rumination,  717 

Saliva,  action  of,  in  infancj-,  43 

secretion  of,  40 
Salivary  glands,  concretions  in,  668 

diseases  of,  668 

in  infancy,  40 

malformations  of,  668 

Mikulicz's  disease,  669 


Salivary  glands  in  mumps,  494 
ranula,  668 

secondary  inflannnation  in,  669 
Salivation  from  stomatitis,  652,  654,  (556 
Salvarsan,       581.     See       Arsphenainine, 

under  Syphilis. 
Salts,  absorption  of,  51,  132 
action  of,  in  food,  100,  132 
in  cow's  milk,  99,  112,  132 
function  of,  in  food,  51,  100,  132 
in  human  milk,  97,  100 
Salt-solution.     See     Enemata.     Ifypoder- 

tnoclysis,  Enteroclysis,  etc. 
Sanatogen,  168 
Sand,  intestinal,  732 
Scalp,  care  of,  70 

in  cephalhematoma,  270 
in  infancy,  34 
in  rickets,  596 
in  syphilis,  573 
Scarlatina,  309.     See  also  Scarlet  fever. 
afebrilis,  320 
anginosa,  321 
hemorrhagica,  323 
miliaris,  315 
papulosa,  315 
pemphigoides,  316 
sine  angina,  320 
sine  eruptione,  320 
typhosa,  321 
variegata,  315 
Scarlet  fever,  309 
abortive,  320 
albuminuria  in,  317 
anginose,  321 
arthritis  in,  325 
atypical  forms,  319 
blood  in,  317 
cellulitis  in,  324 
circulatory  system  in,  327 
complications  and  sequels,  323 
desquamation,  317 
diagnosis,  330 
diphtheria  in,  328 
duration  of  infection,  312 
ears  in,  323 
eruption,  314 
duration  of,  315 
retrocession  of,  316 
normal  variations  of,  315 
etiology,  309 

gastro-intestinal  symptoms  in,  327 
germ  of,  310 
heart  in,  327 
history,  309 
incubation,  313 
invasion,  313 
joints  in,  325 
kidneys  in,  325 
lesions,  312 

lymphatic  glands  in,  31G,  324 
malignant,  322 
meningitis  in,  328 
mild,  319 
morbilliform,    315,    353.     See    also 

Measles. 
mortality  of,  330 
mouth  and  throat  in,  31(5 


INDEX 


879 


Scarlet  fever,  myocarditis  in,  327 
nephritis  in,  325 
nervous  symptoms  in,  328 
nose  in,  323 
otitis  in,  323 
other   infectious   diseases   combined 

with,  328 
pathological  anatomj-,  312 
pneumonia  in,  327  ' 
prognosis,  329 
prophylaxis,  332 
pulse  in,  316 
quarantine,  332 
recurrence,  329 
.relapse  in,  328 
respiratory  system  in,  327 
rudimentary,  320 
severe  form,  320 
surgical.  316 
susceptibility  to,  310 
symptoms.  313 
temperature  in,  316 
throat  in,  316,  323 
transmission,  311 
treatment.  332 
serum-,  333 
typical  course,  313 
urine  in.  317 
Schick  reaction  in  diphtheria,  460 
Schloss  modified  milk,  160 
School,  air-space  in  room  required  for,  79 
School-life,  78 
Sclerema  neonatorum,  299 

in  cholera  infantum,  742 
Scleroderma  in  newborn,  300 
Scorbutus.  602 
bones  in,  607 
complications,  608 
course  and  prognosis,  609 
diagnosis,  609 
effect  of  foods  in,  603 
etiology,  603 
experimental,  604 
gums  in.  606 
pain  in,  605 

pathological  anatomy,  604 
symptoms,  605 
treatment,  609 
Scrofula,  557,  630,  632 
Scurvy,    infantile,    602.     See    also    Scor- 
butus. 
Sedative  drugs,  228 
Senses,  special,  development  of,  65 
Sepsis  in  newborn,  258 
Septic  sore  throat,  674.     Sec  also  Phar- 

yngilis  pseudomembranous. 
Serous  fluids,  svmptoms  connected  with, 

207 
Serum  disease,  464 
therapy,  245 

in  cerebrospinal  fever,  433 
in  diphtheria,  462 
in  tetanus.  517 
Shirt,  71.  74 
Shoes,  73,  74 
Shower-bath,  241 
Sick-room,  80,  307 
Sight,  development  of,  65 


Sinuses  of  nose,  development  of,  53 
Skimmed-milk,  117 

mixtures,  139 
Skin,  hygiene  of,  68 

in  infanc}',  19,  32 

significance    of    svmptoms    connected 
with,  195 
Skull.     See  Head. 
Sleep,  74 

in  adenoid  growths,  687 

in  chronic  intestinal  indigestion,  772 

in  colic,  729 

covering  during,  76 

hours  for,  74 

place  for,  75,  77,  80 

in  rickets,  597 

in  syphilis,  571 
Slip  for  infancy,  72 
Smallpox,  365.     See  also  Variola. 
Smell,  development  of  sense  of,  66 
Soap-stick,  233 
Socks,  71 

Soda-solution  in  acidosis,  232 
Somatose,  167 
Soson,  167 

Soy-bean  flour,  152,  155 
Speech,  acquiring  of,  67 
Spice-bag,  239 
Spine  in  poliomyelitis,  528 

in  rickets,  593 
Spleen  in  cirrhosis  of  liver,  839 

in  chronic  valvular  disease.  840 

in  diphtheria,  446 

in  early  life,  63 

in  malaria,  510 

in  rachitis,  590 

in  syphilis,-  565,  573,  577 

in  tuberculosis,  546 
Sprays,  238 

Sprue,  655.     See  also  Thrush. 
Sputum,  expectoration  of,  204 

failure  to  expectorate,  240,  560 

obtaining  for  examination,  204,  560 
Starch,  action  of,  in  food,  49,  99,  130 

caloric  value  of,  53.  175 

digestion  of,  43,  44,  49,  130, 

effect  of,  in  cow's  milk,  130 

injury  done  by,  130,  616,  771 
Starchy  foods,  152 

caloric  value  of,  175 
Status  lymphaticus,  632 
Steffen's  veal-broth  and  milk,  159 
Stenosis  of  anus,  783 

of  intestine,  781,  783 

of  pylorus,  707 
Sterilization     of     milk,     125.     See     also 

Milk,  cow's. 
Still's  disease,  625.     See  also  Rheumatism. 
Stimulants,  223,  229.     See  also  Alcohol. 
Stockings,  73 
Stomacli.     See  also  Digestion. 

absorption  from,  44 

bacteria  of,  45 

capacity  of,  40 

cardiospasm,  714 

digestion  in,  43 

dilatation  of.,  714 

diseases  of.  <)96 


880 


INDEX 


Stomach,  emptying  of,  44 

foreign  bodies  in,  717 

in  acute  gastric  indigestion,  719 

in  acute  gastritis,  721 

gastro-enteric  intoxication,  739 

in  chronic  gastric  indigestion,  723 

hair-ball  in,  718 

hemorrhage  from,  716 

inflammation  of,  721 

in  acute  intestinal  indigestion,  736 

lavage  of,  246 

malformations  of,  718 

malposition  of,  718 

morbid  growths  of,  719 

pain  in,  704.     See  also  Gastralgia. 

position  of,  41 

pylorus,  size  of,  41 
stenosis  of,  707 

in  rickets,  597 

secretions  of,  41,  43 

tuberculosis  of,  557 

ulcer  of,  716 
Stomatitis,  aphthous,  653 

catarrhal,  652 

diphtheritic,  663 

gangrenous,  659 

gonorrheal,  663 

herpetic,  653,  663 

maculofibrinous,  653 

parasitic,  655.     See  also  Thrush. 

pseudomembranous,  664 

secondary,  663 

syphilitic,  571,  664 

ulcerative,  657 
Stools,  731.     See  also  Feces. 

indications  derived  from,  205,  731 
Stridor  in  diphtheritic  laryngitis,  449 
Strychnine,  228 
Stupe,  turpentine,  239 
Subungual  fibroma,  665 
Substitute  feeding,  108.     See  also  Artifi- 
cial feeding. 
Sucking  cushions,  43  ^ 

interfered  with  by  Bednar's  aphthae, 
664 
by  stomatitis,  653,  654,  656 

method  of,  43 
Sudden  death,  216,  632.     See  also  Death 

and  Mortality. 
Sugar.      See  also  Carbohydrates. 

absorption  of,  49 

action  of,  in  food,  49,  50,  99,  128 

amount  to  be  used  in  milk-mixtures, 
133 

cane,  49,  129 

digestion  of,  49,  99,  128 

disaccharides    and    monosaccharides, 
49 

effect  of,  on  stools,  732 

indigestion,  symptoms  of,  produced  bv, 
178,  179,  697,  764,  771 

maltose,  129 

measuring  of,  135 

in  cow's  milk.  111,  128 

in  human  milk,  96,  99 

relative     assimilability     of     different 
forms  of,  50 

selection  of  variety,  129 


Sugar,  tolerance  of  milk-sugar,  50 
in  urine,  61,  639 
varieties  of,  49,  128 
weight  of  different  kinds,  153 
Suppositories,  233 
Suprarenal  glands,  in  early  life,  63 
Surface   of   bodv,    svmptoms   connected 

with,  195 
Susceptibility  to  certain  drugs,  223.     See 

also  Drugs. 
Sutures  in  infantile  atrophy,  613 

in  rickets,  592 
Swedish  movements,  249 
Symptoms,  significance  of,  194 

abdomen,  200 

blood,  207 

bowel-movements,  205 

breath,  204 

cough,  203 

cry,  202 

face  and  expression,  196 

head  and  neck,  197 

mouth  and  throat,  198 

movements  of  body,  194 

nervous  disturbances,  207 

pain,  204 

position  of  body,  194 

pulse,  201 

respiration,  200 

serous  cavities,  207 

stools,  205 

sucking,  200 

surface  of  body,  195 

swallowing,  200 

temperature,  202 

thorax,  198 

urine,  206 

vomiting,  205 
Syphilis,  562 

abortion  in,  564,  566,  577 

acquired,  563 

alopecia  in,  570 

anemia  in,  577 

arsphenamine  in,  581 

arthritis  in,  575 

of  bones  and  joints,  571,  574 

Colles'  law,  564 

contagion  of  hereditary  form,  580 

coryza,  571 

craniotabes  in,  572 

cutaneous  symptoms,  567,  575 

dactylitis,  571,  575 

diagnosis,  579 

duration,  578 

early  manifestations,  566 

epiphysitis  in,  565,  571 

eruption,  567,  575 

etiology,  563,  564 

eyes  in,  577 

fetal,  565 

fissures,  569 

frequency',  562 

gummata,  574,  577 

hair  in,  570 

hearing,  577 

hemorrhage  in,  571 

hereditary,  564 

infantile,  ,566 


INDEX 


881 


Syphilis,  joints,  575 

kidneys,  573 

larynx,  577 

later  sj^philitic  manifestations,  573 

lesions,  563,  564 

liver,  573 

lymphatic  glands,  571,  577 

microorganisms,  563 

mortality,  577 

mucous  membranes,  571,  577 
patch,  567,  571,  577 

naiis  in,  569 

nervous  svstem,  577 

nose,  565,"  572,  575 

nutrition,  573,  574 

osteochondritis  in,  571 

osteoperiostitis,  574 

otitis,  577 

pathological  anatomy,  563,  564 

pemphigus,  567 

postconceptional,  564 

prognosis,  577 

Profeta's  law,  580 

prophylaxis,  580 

pseudoparah'sis,  571,  577 

rhinitis,  565 

skin,  567,  573,  575 

spleen,  565,  573 

symptoms,  566 

teeth,  576 

tertiary,  574 

transmission  of,  563,  564 

treatment,  580 
Syringing  nose  and  throat,  238 
Szekely's  casein-free  milk,  159 

Tabes  mesenterica,   556.     See    Tubercu- 
losis and  Lymphatic  glands. 
Taenia,  823 

cucumerina,  825 
elliptica,  825 
flavopunctata,  825 
mediocanellata,  824 
nana,  825 
saginata,  824 
solium,  824 
treatment,  826 
Tendency  to  disease  at  different  ages,  209 
Tenesmus  in  constipation,  759 
in  ileocolitis,  750 
in  intussuscepti(jn,  787    . 
in  proctitis,  814 
Tetanus,  513 
diagnosis,  516 
etiology,  513 
germ  of,  514 
neonatorum,  514 
in  oder  children,  515 
proghosis,  516 
treatment,  516 

with  antitoxin,  517 
Therapeutics  of  early  life,  219.     See  also 
Drugs. 
administration    of    mediciiies    liy 

the  mouth,  220 
anesthetics,  24S 
appl'cations  to  no.sc  and   tlmmt, 

237 
56 


Therapeutics  of  early  life,  blood-letting, 
245 
climatotherapy,  250 
counter-irritation,  238 
dosage,  222,  229 

according  to  age,  223 
drugs  by  mouth,  220 
grouped    according    to    action, 
228 
drv  cold,  244 

heat,  245 
electricity,  250 
enemata,  233 
enteroclysis,  235 
gargles,  237 
gavage,  247 

gymnastic  exercises,  249 
hydrotherapy,  239 
hypodermic  medication,  231 
hypodermoclysis,  231 
inhalations,  235,  236 
insufflations,  238 
intraperitoneal  injection,  232 
intravenous  injection,  245 
inunctions,  237 

irrigation  of  intestine,  233,  234 
lavage,  246 
massage,  249 
mechanotherapy,  249 
method  of  grouping  medicines,  220 
nasal  feeding,  248 
other  than  by  drugs  by  mouth, 
0-~-__231 

ffeaj)metric  table,  230 

' psychotherapy,  248 

radiotherapy,  250 
serum-therapy,  245 
suppositories,  233 
susceptibility  to  certain  drugs,  223 
syringing  of  nose  and  throat,  238 
table  of  doses  at  one  year,  229 
transfusion  of  blood,  246 
treatment  other  than  by  drugs  liy 

mouth,  231 
vaccine-therapy,  245 
Thorax  in  adenoid  growths,  689 
circumference  of,  35 
growth  of,  35 
influence  of  sex  on,  36 
in  infancv,  35 
in  rachitis,  588,  592 
relation  to  size  of  head,  36 
svmptoms  connected  with,  198 
Thread-worms,  820 
Throat.     See  also  Pharynx. 
applications  to.  237 
in  scarlet  fever,  316,  323 
symptoms  connected  with,  198 
Thrombosis  in  diplitheria,  455 
in  recurrent  vomiting,  703 
in  typhoid  fever,  40(i 
of  unil)ilical  vessels,  290 
Tlirush,  ()55 

Thymus  gland  in  early  life,  62 
length  of,  ()2 
in  lyiiiphutism,  633 
weight  of,  62 
Thyroid  gland  in  early  life,  63 


882 


INDEX 


Toilet,  bath,  68,  70 

of  .scalp,  OS,  70 
Tongue,  black.  Odd 

congonital  hypertrophy  of,  (')(i4 

diseases  of,  664 

enlargement  of,  664 

epithelial  desquamation  of,  667 

geographical,  067 

inflammation  of,  667.     See  also  Glossilis. 

macroglossia,  664 

sublingual  fibroma,  665 

swallowing  of,  667 

tumors  of,  665 

ulceration  of  frenum,  665 
Tongue-tie,  665 
Tonics,  229 

Tonsillitis,    acute    catarrhal,     671.     See 
•  also  Pharyngitis. 

diphtheritic,  447,  451 

follicular,  079 

lacunar,  acute,  679 
chronic,  681 

parenchymatous,  683 

phlegmonous,  683 

pseudomembranous,      674.     See     also 
Fiic  lido  membranous  pharyngitis. 

ulceromembranous,  682 
Tonsils  in  diphtheria,  447,  451 

diseases  of,  679 

faucial,  hypertrophy,  684 

lingual,  hypertrophy  of,  684 

pharyngeal,  hypertrophy  of,  686.     Sec 
also  Adenoid  vegetations. 

in  rachitis,  597 

tuberculosis  of,  557,  679 

tumors  of,  679 
Top-milk,  115.     See  also  Milk,  coio's. 

mixtures,  139 
Torticollis    in    retropharyngeal    abscess, 
677 

rheumatic,  626 

spasmodic,  411 
Touch,  development  of  sense  of,  66 
Towels,  70 
Trachea,  fistula  in,  691.     See  also  Tra- 

cheo-esophagea  I  fist  n  lo . 
Tracheo-esophageal  fistula,  692 
Training  and  amusements,  77 
Transfusion  of  blood,  246 
Transitory  fever  in  newborn,  302 
Treatment,  219.     Sec  also  Therapeutics. 
Trichocephalus  dispar,  831 
Tuberculin  reactions,  560 
Tuberculosis,  538 

acute  miliary,  547 

of  alimentary  tract,  557 

bacilli  of,  542 
in  milk,  544 
portal  of  entry,  543 
situation  of,  543 
transmission  of,  543 
varieties  of,  .542 

blood  in,  559 

bronchopneumonia  in,  550,  553 

of  cervical  glands,  558 

clinical  forms,  547 

congenital,  539 

diagnosis,  559 


Tuberculosis  of  digestive  tract,  557 

etiology,  538 

predisposing  causes,  539 
exciting  cause,  542 

frequency  of,  538 

general,  547 

of  genito-urinary  tract,  557 

of  glands,  55(5 

hemoptysis  in,  552,  559 

hilu.s-,  .554 

incidence  of,  540 

of  intestine,  557,  798 

of  kidne.v,  557 

of  larynx,  546 

lesions,  544 

oftene.st  causing  death,  547 

of  lungs,  550,  et  seq. 

of  lymphatic  glancls,  556,  557 
cervical,  557 
general,  557 
mesenteric,  556 
tracheobronchial,  556 

marantic  form,  549 

after  measles,  350 

of  meninges,  558 

of  m(>senteric  glands,  556 

method  of  transmission,  543 

miliary,  of  lungs,  550 

mode  of  infection,  543 

mortality,  558 

of  nervous  system,  558 

pathological  anatomy,  544 

of  penis,  557 

of  peritoneum,  558,  851 

in  pertussis,  488 

phthisis,  556 

of  pleura,  558 

portal  of  entry,  543 

primary  lesion,  546 

primary  pulmonary  foci  of  Ghon,  554 

prognosis,  558 

prophylaxis,  561 

regions  oftenest  affected,  545 

of  serous  membranes,  558 

of  spleen,  546 

sputum  in,  560 

of  tonsils,  557,  679 

of  tracheobronchial  glands,  556 

treatment,  56 1 

tuberculin  reaction  in,  560 
_    typhoid  form,  547 

x-ray  examination  in,  560 
Tuberculous     adenitis,     556.     See     also 
A denitis,  tuberculous. 

bronchopneumonia,    acute,    550,    553. 
See  also  Pneuuionia,  broncho. 
subacute  and  chronic,  553 

meningitis,  558 

peritonitis,  558,  852 

pleuritis,  558 
Tumors.     See  Growths,  morbid. 
Turpentine  stupe,  239 
Tympanites,  728 

in  chronic  intestinal  indigestion,  765, 
772 

in  dilatation  of  colon,  778 

in  peritonitis,  846 
.    in  rachitis,  597 


INDEX 


883 


Tympanitos  in  tuberculous  peritonitis,  854 

in  typhoid  fever,  395 
Typhoid  fever,  390 
abortive.  403 
blood  in,  398 

circulatory  apparatus,  400 
complications,  404 
congenital,  391,  400 
cutaneous  symptoms,  395,  408 
diagnosis,  410 

digestive  symptoms,  394,  400 
in  early  childhood,  402 
emaciation  in,  400 
eruption,  395 
etiology,  390 
fetal,  391,  400 

gastro-intestinal  symptoms,  394,  406 
genito-urinary  symptoms,   400,   408 
germ  of,  391 
hemorrhage  in,  406 
hemorrhagic,  406 
incubation,  394 
infantile,  401 
invasion,  394  * 
in  later  childhood,  402 
mild,  403 
mortality,  410 
nervous,  404 

symptoms,  400,  408 
ordinary  course,  394 
other   infectious   diseases   combined 

with,  409 
otitis  in,  408 

pathol(jgical  anatomy,  392 
perforation,  407 
period  of  infectiousness,  392 
prognosis,  410 
pulse,  399 
recrudescence,  409 
recurrence,  410 
relapse,  409 

respiratory  symptoms,  400,  404 
roseola,  395 
serum-reaction,  399 
sequels,  404 
spleen  in,  395 
symptoms,  394 
temperature  in,  396 
transmission,  method  of,  391 
treatment  of  attack,  412 

of  complications  and  sequels,  415 

imniuiiizing,  412 

jjrophy lactic,  412 
urine  in,  400 
variations  in  course,  400 
^^'idal  reaction,  399 

IIlckkomk.mhu.woi's  tonsillitis,  6S2 
ricers,  duodenal,  797 

gastric,  71() 

in  gastritis,  721 

intestinal,  797 

of  mouth,  657,  663 
of  palate,  664 

of  stomach,  7I() 

of  tonsils,  6S2 

in  typhoid  fever,  303 

of  umbilicus,  286 


Umbilical  cord,  dressing  of,  68.  72 
falling  of,  37 
ligation  of,  68 
Umbilicus,  arteritis  of,  290 

diseases  of,  286 

fungus  of,  287 

gangrene  of,  289 

granuloma  of,  287 

healing  of,  delayed,  286 

hemorrhage  from,  292 

inflammation  of,  288 

omphalitis,  288 

omphalorrhagia,  292 

peri-omphalitis,  288 

phlebitis,  290 

polypus,  287 

protruding       Meckel's      diverticulum, 
295 

sarcomphalos,  287 
Uncinaria,  829 
Uremia  in  scarlet'fever,  326 
Urine,  acetone  in,  61 

albumin  in.     See  Albumimina. 

amount  normally  secreted,  liO 

blood  in,  206 

characteristics  of  normal,  (51 

composition  of,  61 

control  of,  65 

in  diabetes,  639 

in  early  life,  60 

examination  of,  192 

frequency  of  passing,  normal,  61 

hematuria,  206 

hemoglobinuria,  206,  262 

increased  secretion  of,  206,  639,  642 

method  of  obtaining,  192 

polyuria,  206,  639,  642 

quantity'  secreted  normally,  (50 

reaction  in  infancy,  61 

retention  of,  206 

in  scarlet  fever,  317 

specific  gravity,  61 

sugar  in,  61,  (j39 

suppression  of,  206 

symptoms  connected  with,  20() 

mic  acid  in,  61 
Urticaria    in    chronic   intestinal    indiges- 
tion, 772 

after  serum-injections,  435.  464 
Uvula,  bifid,  (i71 

edema  of,  673 

elongated,  673 

inflammation  of,  673 
Uvulitis,  673 

Vaccination,  370 
age  for,  376 

complications  and  scfiucls,  3S2 
cour.se,  377 
etiology,  376 
generalized,  379 
irregularities  in  course,  37S 
method,  37() 
mortality  from,  3S3 
protective  |)()\ver  of,  3S1 
revaccination,  3S() 
spurious,  .3S0 
symptoms,  378 


884 


INDEX 


Vaccine  therapy,  2-45 
in  erysipelas,  442 
in  grippe,  481 
in  pertussis,  494 
in  typhoid  fever,  412 
Vaccinia,  376.     See  also  Vaccination. 
Vapor-bath,  242 
Varicella,  383 

complications  and  sequels,  388 
confluent,  387 
diagnosis,  389 
eruption,  384 
etiology,  383 
gangrenous,  388 
hemorrhagic,  388 
irregularities  in  course,  387 
pathological  anatomy,  384 
relapse  and  recurrence,  388 
symptoms,  384,  386 
transmission,  384 
treatment,  389 
Variola,  365 

complications  and  sequels,  371 
confluent,  370 
desquamation,  369 
diagnosis,  373 
discrete,  366 
etiology,  365 
eruption,  367 
hemorrhagic,  370 
incubation,  366 
invasion,  366 
mild,  370 
modified,  370 
pathological  anatomy,  365 
prognosis,  372 
purpura  variolosa,  370 
pustulosa  hemorrhagica,  370 
quarantine,  374 
relapse  and  recurrence,  372 
symptoms,  366 
transmission,  365 
treatment,  374 
varioloid,  370 
vera,  366 
Varioloid,  370.     See  also  Variola. 
Veins,  dilatation  of,  in  cirrhosis  of  liver, 
840 
in  morbid  growths  of  abdomen,  196 
in  rachitis,  592 

in  tuberculous  peritonitis,  854 
in  syphilis,  573 
umbiHcal,  56 
Venesection,  245 
Vernix  caseosa,  19 
Vigier's  humanized  milk,  159 
Vincent's  angina,  682.     See  also  Ulcero- 
membranous tonsillitis. 
Voice,  alterations  of,  in  adenoid  vegeta- 
tions, 688 
in  catarrhal  pharyngitis,  .672 
in  diphtheritic  paralysis,  454 
in  hypertrophied  faucial  tonsils,  685 
in  laryngeal  diphtheria,  449 
in  measles,  344 

in  parenchymatous  tonsillitis,  683 
in  retropharyngeal  abscess,  677 
in  syphilis,  566,  571 


Voltmcr-Lahrmann's   pancroatized   milk, 

159 
Volvulus,  of  intestine,  783 

of  Meckel's  diverticulum,  810 
Vomiting,  700 

acetonemic,  702 

in  appendicitis,  701,  802 

in  cerebrospinal  fever,  422 

cyclic,  701 

after  cough,  701 

fecal,  782,  787  _ 

in  acute  gastric  indigestion,  700,  719 
gastritis,  721 

in  chronic  gastritis,  700,  724 

habit,  700 

in  acute  infectious  diseases,  700 

in  intestinal  obstruction,  782 

in  intussusception,  787 

in  organic  nervous  diseases,  700 

nervous,  700 

obstructive,  701 

overloading  of  stomach,  700 

in  passive  congestion  of  stomach,  701 

in  peritonitis,  701,  846,  854 

in  pyloric  stenosis,  710 

recurrent,  701 

reflex,  701 

stercoraceous,  782,  787 

toxic,  701 

in  typhoid  fever,  394 

in  ulcer  of  stomach,  717 
Von  Dungern's  renneted  milk,  158 
Von  Pirquet  cutaneous  reaction  in  tuber- 
culosis, 560 

Walking,  age  of  learning,  65 

in  appendicitis,  802 

in  rachitis,  596  _ 
Water,  action  of,  in  food,  99 
Weaning,  89 

causes  for,  86,  87,  89 
Weight  at  birth,  20 

before  and  after  nursing,  87,  92 

changes  in  first  two  weeks,  21 

chart  for  recordmg,  28,  29 

of  clothing,  26 

failure  to  gain,  87 

in  first  year,  22-24 

influence  of  season  on,  27 

from  second  to  sixth  year,  24 

from  sixth  to  sixteenth  year,  25 
Weil's  disease,  835 
Wet-nurse,  baby  of,  90,  91 

hygiene  of,  92 

selection  of,  91 
Wet-nursing,  advantages  of,  90 

in  infantile  atrophy,  614 

objections  to,  90 

in  premature  infants,  256 
Whey,  130,  145 

caloric  value  of,  175 

composition  of,  145 

importance  of,  in  milk-mixture,  131 

purpose  of  reduction  of  amount  of,  130, 
697 

use  in  modifying  milk-mixtures,    120, 
146 
Whey-cream  mixtures,  145 


INDEX 


885 


Widal  reaction,  399.     See  also   Typhoid 

fever. 
Winckel's  disease,  262 
Whole-milk  mixtures,  139 
Whooping-cough,  482.     See  also  Pertussis. 
Worms,  hook,  828 

intestinal,  818 

pin-,  820 

round,  819 

tape-,  823 

thread-,  820 

Avhip-,  831 

X-RAY  in  diagnosis,  193 

in  dilatation  of  colon,  779 


A'-ray  in  dilatation  of  stomach,  715 

in  foreign  bodies  in  esophagus, 
695 
in  intestine,  817 
in  stomach,  718 
in  intussusception,  790 
in   normal   continuance    of   food   in 

stomach,  44 
in  rachitis,  587 
in  scorbutus,  605 
in  stenosis  of  intestine,  782 
of  pylorus,  712 
in  treatment,  250 

Youth,  19 


I 


